Critical Access Hospital (CAH) and CAH Swingbed Questions and Answers

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1 Critical Access Hospital (CAH) and CAH Swingbed Questions and Answers The following questions and answers are from the April 2012 CAH and CAH Swingbed web-based trainings: Q1. Is a non-covered/no pay bill required for a patient that does not meet swing bed or inpatient care (i.e., Respite Care)? A1. If you are admitting a patient as an inpatient to the hospital or swingbed that does not meet coverage criteria, a no-pay claim should be submitted. Q2. Does the Information-Only Claims information on slide 20 affect the doctor billing for professional fees? A2. No; the Information-Only Claims instructions apply only to facility claims. Q3. What type of bill is used for Information-Only claims (shadow billing)? A3. The types of bill are 111 for inpatient hospital, 211 for inpatient SNF and 181 for swingbed claims. Information about the requirements can be found in the CMS IOM Publication , Chapter 3, Section Q4. What revenue code should be used for anesthesia services? A4. Anesthesia drugs and supplies should be billed under revenue code 37X. Certified Registered Nurse Anesthetist (CRNA) services are billed under revenue code 964 for both the pass-through and Method II payment options. Physician anesthetist services are billed under revenue code 963 when provided to hospital outpatients under Method II. Q5. Under Method II, would we ever bill CRNA services under a revenue code 0964 verses revenue code 0982 as a pass through? A5. CRNA services always should be billed under revenue code If a Method II CAH also is eligible for the CRNA pass through, it must decide whether the CRNA will be included as a Method II practitioner or if it will bill CRNA services as a pass through expense. Once that determination is made, the payment method is recorded in the contractor s provider files, and the payment is calculated according to that information. Under the CRNA pass-through provisions, both inpatient and outpatient CRNA services can be included on the UB04 claim. If the facility decides to include the CRNA as a Method II provider, all inpatient CRNA services must be billed separately to Part B on a 1500 claim form.

2 Q6. Under CAH Method II billing, if a patient is being seen by the doctor (99225) in an observation stay, should this be billed to Part A or Part B? A6. Under Method II, outpatient professional services are billed on the UB04 along with the facility charges. As outpatient services, they will be paid under Part B benefits. Q7. If a physician reassigned benefits under Method II, does that apply to all services, or can it be applied only to certain services? A7. If a physician has reassigned benefits under Method II, all outpatient hospital services that physician provides must be billed by the hospital on a UB04 billing. The election cannot be applied selectively for certain patients or certain procedures. Q8. When billing Medicare Advantage for urgent care clinic physician services under Option II billing, urgent care told me that we should be billing all clinic charges on the A8. If the urgent care clinic is hospital-based, it is considered an outpatient department of the hospital. As such, the clinic charges (and the professional fees if the physicians have reassigned benefits under Method II) should be billed on a UB04 claim. Please refer to CMS Program Memorandum A for more information about providerbased status ( Guidance/Guidance/Transmittals/downloads/a03030.pdf). Q9: Should we be billing CPT 97802, nutrition education, on a UB with a modifier? A9. When billing professional services for nutritional therapy, the services should be reported under revenue code categories 096x or 098X. If the services are provided by a nutritional professional or registered dietician, use modifier AE. Q10. Do you use Addendum B to determine the coinsurance for Part B services? A10. CAHs are subject to the same Part A benefit period, deductible and coinsurance and Part B annual deductible and coinsurance provisions as PPS hospitals. However, because CAHs are paid based on cost rather than under a Prospective Payment System (PPS), the coinsurance is based on 20% of billed charges rather than the amounts listed in Addendum B for PPS services. Q11. Regarding modifier TC, does this apply only to professional fees? A11. Modifier TC is used when billing technical components on a 1500 claim form. While it may be submitted on a UB-04 or electronic equivalent, is it not used as part of the payment calculation. Instead, technical and professional components are determined strictly by the revenue code assigned to the service.

3 Q12. When would we use condition code B2 on an ambulance claim? Will it make a difference in reimbursement? A12. Condition code B2 indicates that the CAH-based ambulance is the only ambulance provider within 35 miles of the CAH, or that if the CAH-based ambulance barn is more than 35 miles from the CAH, the other ambulance is not closer to the CAH than the CAH-based ambulance. When B2 is added to the claim, the ambulance charges are paid at cost instead of under the ambulance fee schedule. Q13. Does a CAH have to put the CPT code in highest to lowest ranking to be paid correctly when billing for multiple surgical procedures? A13. The claims processing system automatically ranks the procedures from highest to lowest as part of the payment calculation. Q14. Does the multiple procedure billing process on slide 48 apply to more than one ER visit in the same day? A14. No; the instructions apply to multiple surgical procedures performed by the same physician or physicians in the same group practice on the same patient during the same operative session or on the same day. Q15. If a patient comes to our ER twice in 24 hours, can we bill for 2 visits? A15. Yes, both visits could be billed. Q16. If we have patient present to the emergency department close to midnight and continue services into the next day then come in later that day, would we need to include this all on one bill due to the service dates, or should the ER admission be only for the date it occurred. Would the Professional fee and facility fee be billed as the admission date or the discharge date? A16. All services for the same date of service need to be on one claim, so these services should be billed together on one claim. Use the date the emergency room service was initiated as the line item date of service for that service for both the facility and the professional charges. Example: Patient presents at 10:30 p.m. on 1/2/12, and receives evaluation and management (E&M) services that last until 4:00 a.m. Patient returns at 8 p.m. on 1/3/12. The claim from through date of service would be 1/2/12-1/3/12. The first E&M service would be shown with line item date of service 1/2/12 (even though services extended over into 1/3/12), and the second service would be shown with line item date of service 1/3/12. All other services provided during these visits would be listed under the line item dates they were provided.

4 Q17. If a provider writes an order to discharge from Observation and at the same time writes an order for a lab test, when does the observation time end? A17. Observation time ends when all medically necessary services related to observation care are completed. This could be before discharge when the need for observation has ended, but other medically necessary services not meeting the definition of observation care are provided. If there is no need for additional observation services, the observation would end with the discharge order rather than upon completion of the lab services. Please refer to CMS IOM Publication , Chapter 4, Section for further discussion of observation time. Q18. If an observation patient has an order for discharge and nurses complete the discharge paper work, then we count that time for observation, correct? A18. Yes, that is related to the observation care. Q19. Would PT/OT services during an observation stay be included on the same claim with the observation charges? A19. Yes, but the time spent in therapy would not be included in the observation hours. Q20. If a patient is in observation and goes to the CT department for a CT, do you deduct the time the patient is in the CT department for the exam from observation time? A20. Observation should not be billed concurrently with diagnostic or therapeutic services when active monitoring is a part of the procedure. The time for the CT should be deducted from the observation time. Please refer to IOM Publication , Chapter 4, Section for further information. Q21. We have a patient in observation now that is going by ambulance for CT at another facility. Can I bill the ambulance and can the other facility bill the CTs? A21. The patient is in an outpatient status, so you do not need to include the CT services provided by another facility in your claim. You would include the ambulance charges only if the ambulance is hospital-based. Had the patient been an inpatient, the ambulance charges would be bundled into the charges for the CT, and the CT would be included in your inpatient hospital claim. Q22. When observation hours span two dates do we report the hours separately for each date or do we combine them, for example, the patient is seen 4/25 (5) hours then 4/26 (5 hours)? A22. The total time would be billed on one line using the beginning date as the line item date of service. In this case, 10 hours of observation would be reported using 4/25 as the line item date of service.

5 Q23. How do we bill observation time over 48 hours? A23. Hours over 48 are reported on a separate line item as non-covered. Q24. If we believe that the observation continued to be medically necessary after 48 hours, should we include those hours in the covered line? A16. No, the hours above 48 will have to be billed separately as non-covered. If you feel the documentation supports coverage of additional observation hours, submit the claim as instructed and when the claim has completed processing and the second observation line item has been rejected, call the Provider Contact Center for assistance in having the additional services reviewed. Q25. Regarding the G0379, if the patient is a direct admit from a provider based clinic, you would not bill the G0379 since it is a hospital outpatient clinic visit, correct? Would you then bill the G0379 in the same situation for non PBB payers? A25. Hospitals should only report HCPCS code G0379 when a patient is referred directly for observation care after being seen by a physician in the community. It should not be used if the observation services are the result of a referral for observation care with an associated emergency room visit, hospital outpatient clinic visit, critical care service, or hospital outpatient surgical procedure (status indicator T procedure) on the day of initiation of observation services. Q26. If admitted as observation from the emergency room, would you only use G0378? A26. G0378 is used to report the number of hours of observation. The services that resulted in the observation referral also would be reported, i.e., E&M code from the emergency room. Q27. Do we use an admission HINN or ABN for noncovered not medically necessary observation time? A27. HINNs are inpatient notices; an ABN is used for outpatient services. Q28. We have a Medicare Advantage patient that was placed in inpatient but denied as not meeting medical necessity. Can we bill it as observation now? A28. If your facility contracts with the Medicare Advantage plan, check with the plan to see if special provisions apply. Under fee-for-service Medicare, the services could not be billed as observation; and would have to be billed as inpatient Part B according to the provisions in IOM , Chapter 6, Section 10.

6 Q29. Where is the information on inpatients in the benefit policy manual? A29. Information about inpatient services is found in Chapter 1, Section 10 of the Medicare Benefit Policy Manual (IOM Publication ). Please refer also to MLN Matters SE1037 at Network-MLN/MLNMattersArticles/Downloads/SE1037.pdf ; this article provides guidance on inpatient decisions and gives additional resources. Q30. Can you please direct me to the CMS information where the Physician Scarcity Area (PSA) bonus was extended? A30. The information as presented was in error. The PSA bonus expired June 30, Q31. How are bonus payments identified when made? A31. The bonus payments are issued quarterly and are identified separate from other claims payments on your remittance advice. CAH Swingbed Q1. What is type of type of bill 181? A is a covered swing bed admit through discharge claim. Q2. Please clarify slide 17, a readmission to skilled swing bed does not need to be related to the original inpatient diagnosis? A2. Readmission can be for the same diagnosis or a condition that was treated during the prior stay. Q3. Is type of bill 182 a readmit to swing bed? A3. Type of bill 182 is used for patients who are in the facility for more than one billing cycle. 182 is used for the first month, 183 for the subsequent month(s), and 184 is used for the discharge month. If the stay involves only two months, you would not have an 183. You would bill using TOB 181 if the patient is admitted/readmitted and discharged within the same billing cycle. Q4. Would a CAH swing bed only use type of bill 181? A4. No, 181 applies to any covered swing bed claim where the patient is admitted and discharged within the same month.

7 Q5. Should swing bed claims be billed monthly or can a single claim for multiple months be billed at once? A5. Monthly bills are required when applicable to the length of stay. The exception is the no-payment claims. Q6. If the patient is in a covered swing stay and requires an MRI, will the MRI go on TOB 181 as part of the covered swing bed stay or will the MRI be separately billed on TOB 851? A6: The MRI should be included on the 18X swing bed claim. Q7. So if a patient was admitted April 29 and discharged May 4, what TOB would I use? A7. Type of bill 182 would be used for the 4/29-4/30 claim, and type of bill 184 for 5/1-5/4. Q8. In regards to the MRI question, would that include MRA's as well? Revenue code 615? We are having a problem with this revenue code. A8. Yes. Per CMS, none of the SNF PPS and the consolidated provisions applies to CAH swing beds. Q9. I have a general question. Do you know of a workshop like this one for nursing home? I also do nursing home billing and am not able to get my monthly no pay claims to go through and am looking for any help. A9. We do not have one scheduled at this time, but you can find information about this in the Education Center on our website. Refer to the Skilled Nursing Facility (SNF) section. Q10. For shadow bills, can the ancillaries be on the bill as well? A10. Yes. "Shadow bills", or Information-Only claims, are processed by the A/B MAC for utilization tracking. Q11. Can you explain the qualified stay for Minnesota CAH's? We were under the impression that we must admit a swing bed patient directly following a discharge from a hospital. A11. Under Medicare provisions, the patient must be admitted within 30 days of the qualifying hospital stay, unless there is a medical reason for delaying the admission. Please look at the information in the IOM Medicare Benefit Policy Manual, Publication , Chapter 8, Section 10.3 regarding the application of SNF coverage rules to Swingbed services.

8 Q12. Do we have to bill all non skilled swing beds? A12. Per IOM Medicare Benefit Policy Manual, Publication , Chapter 8, Section 10.3, Swing bed patients who no longer qualify for Part A coverage of SNF-level services under the Medicare program (due to exhaustion of Part A SNF benefits, dropping below a SNF level of care, etc.) revert to receipt of a hospital level of care in the swing bed (see the IOM Medicare Benefit Policy Manual, Publication , Chapter 6, Hospital Services Covered Under Part B, 10). Thus, any further Medicare coverage in the swing bed would be for inpatient hospital ancillary services under Part B, TOB 12X. Q13. I have a claim for a patient that has exhausted their SNF benefits that starts 11/27/11 and ends 12/02/11. Do I have to bill 2 claims, one for November and one for December, or can we bill just one claim? A13. Yes, two claims would be needed. You would need to bill 11/27/11 11/30/11 and 12/1/11 12/2/11. Q14. If we are billing a Medicare HMO claim, we need to send a TOB 12x as an informational bill with a value code 04? Is that Correct? A14. No. Medicare Advantage claims are submitted with TOB 18X. A condition code 04 is required which indicates that the patient is a member of a Medicare Advantage Plan. Contractors will process the claim and the days will be posted to CWF. Please refer to the IOM Medicare Claims Processing Manual, Publication , Chapter 6, Section Q15. Do CAH swing beds follow 5 days per week therapy, restorative therapy programs; provide therapy on holidays to equal 5 days therapy per 7 days? What are considered direct and non-direct skilled nursing services for equating skilled swing bed care? A15. Per the IOM Medicare Benefit Policy Manual, Publication , Chapter 8, Section 30.6, Skilled nursing services or skilled rehabilitation services (or a combination of these services) must be needed and provided on a daily basis, i.e., on essentially a seven days a week basis. A patient whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the daily basis requirement when they need and receive those services on at least five days a week. (If therapy services are provided less than five days a week, the daily requirement would not be met.) Direct skilled nursing services can be found in the IOM Medicare Benefit Policy Manual, Publication , Chapter 8, Section 30.3.

9 Q16. Do you still bill type of bill 181 to a MSHO blue plus? A16. Bills submitted to Managed Care Plan would have to follow the plan requirements for claim submission. A claim would also be submitted to Medicare for tracking utilization. The claim submitted to Medicare would be billed with TOB 18X and a condition code 04 needs to be included. Please refer to the IOM, , Chapter 6, Section 90. Q17. For Hospice patients do we bill Medicare for ancillaries and the hospice provider for room? A17. If the swing bed stay is related to the patient s hospice condition, all services provided would be billed to the hospice. Q18. Can we bill a 360 revenue code on a 181 claim? A18. Yes. Revenue code 360 is allowable on a TOB 18X. Q19. Can you publish a list of allowable revenue codes for the 18X TOB's? A19. There is not an all-inclusive listing of allowable revenue codes for TOB 18X. A listing of the extended care services that a SNF/Swing Bed is expected to provide can be found in the IOM Medicare Benefit Policy Manual, Publication , Chapter 8, Section 10. Providers with access to Direct Data Entry (DDE) can validate whether or not a revenue code is allowable on TOB 18X by utilizing the Revenue Code file (option 13) from the Inquiry Menu. Providers without access to DDE can contact the Provider Contact Center (PCC) at Q20. Do we have to hold the bed for the patient if they take a leave of absence? Would this be the same as leaving against medical advice? A20. Yes. A leave of absence is a bed hold as the patient is not discharged. Hospitals are not permitted to charge the patient. A leave of absence is not the same as leaving against medical advice. Q21. Can you explain benefit periods further? Does it reset 60 days after the last SNF day or yearly? A21. Benefit periods are not reset yearly. A benefit period ends when a beneficiary has not been an inpatient of a hospital, or received daily skilled care in a Swing Bed or SNF for 60 consecutive days.