Medicare Part A Introduction to Skilled Nursing Facility Billing

Transcription

1 Medicare Part A Introduction to Skilled Nursing Facility Billing EMPIRE MEDICARE SERVICES HCFA Medicare Part A and Part B Contracted Agent

2 Medicare Billing Skilled Nursing Facility Table of Contents EXTENDED CARE BENEFIT IN A SNF...1 RE-ESTABLISHING BENEFITS IN A SKILLED NURSING FACILITY...3 RENEWAL OF BENEFITS IN A SKILLED NURSING FACILITY...4 NEW BENEFITS WILL BE AVAILABLE TO PATIENT...5 UB-92 HCFA-1450 (FACSIMILE)...6 SKILLED NURSING FACILITY BILL TYPES...7 SNF CHARGE STRUCTURE REVENUE CODES...8 CODING FOR SKILLED NURSING FACILITIES...9 ONE DAY STAY...11 NO-PAY DISCHARGE BILLS...12 RESUBMITTING COST AVOIDED CLAIMS...13 MAJOR CHANGES FOR BILLING UNDER SNF PPS...14 MDS ASSESSMENT SCHEDULE...15 MDS 2.0 RUG-III CODES...16 RUG CODES (HIPPS)...18 HIPPS MODIFIERS/ASSESSMENT TYPE INDICATORS...19 PART B BENEFITS...21 PART B SNF CHARGE STRUCTURE REVENUE CODES...23 SNF BILLING...24 HCPCS CODING REQUIREMENTS...24 BILLING THERAPY SERVICES...25 UNDER PART B IN A SNF...25 PART B THERAPY BILLING...26 Orientation 2000

3 EXTENDED CARE BENEFIT IN A SNF Medicare beneficiaries may be eligible for up to 100 days of Part coverage in a skilled nursing facility (SNF) if they meet both technical and medical qualifications for coverage. The benefit is dependent upon the resident s need for skilled care. Medicare does not have a long term care custodial benefit. Technical Qualifications: 3 day qualifying hospital stay - must occur while patient is enrolled in Medicare transfer to the SNF within 30 days of discharge - may exceed 30 days if patient is on hold for therapy - may exceed 30 days if patient transfers from one SNF to another (first admission must be within 30 days of hospital discharge; next SNF admission must be within 30 days of last covered day in 1 st SNF) enrolled in Medicare Part A and have benefit days available to use Medical Qualifications: requires skilled care (from a nurse or therapist) on a daily basis as a practical matter services can only be provided in a SNF services are provided for a condition which the patient was treated in the hospital or for a condition which arose while the beneficiary was being treated in the hospital Benefit Periods There is no limit to the number of benefit periods that a beneficiary may qualify for. You may have more than one period of 100 days paid for in a SNF. In order to renew benefits, the SNF resident must: be discharged to home for a period of at least 60 consecutive days (not requiring inpatient care under Part A in a SNF or hospital) remain in the SNF at a non-skilled level of care (custodial) - this requires claims coding by the SNF to indicate the change Orientation 2000 Page 1

4 If these requirements are not met, the beneficiary remains in the same benefit period and may potentially run out of Part A days (benefits exhaust). This beneficiary would be ineligible for new coverage (technically) even if he experiences a new medical condition, had a new hospitalization and return to the SNF meeting the medical requirements for coverage. Orientation 2000 Page 2

5 RE-ESTABLISHING BENEFITS IN A SKILLED NURSING FACILITY 6/1 7/15 30 Days 8/14 9/14 45 benefit days used Occurrence Code 22 or Discharge 60 Days If the resident is cut or discharged on 7/15, the balance of benefits available may be used if the patient returns to the facility or is upgraded to skilled level of care within 30 days (8/14). NO NEW QUALIFYING HOSPITAL STAY IS REQUIRED If the resident returns to the facility or is upgraded to skilled level of care at any point between day 31 and day 60 (8/15 9/14), THAT PATIENT MUST HAVE A QUALIFYING HOSPITAL STAY TO RESUME USING THE BALANCE OF REMAINING BENEFITS. If the resident returns to the facility or is upgraded to skilled level of care at any point after day 60 (9/15) that patient is eligible for a NEW BENEFIT PERIOD, BUT MUST HAVE A QUALIFYING HOSPITAL STAY and meet all other criteria in order for new benefits to apply. NOTE: Any unused benefit days from prior benefit period are lost if the patient enters a new benefit period. NOTE: A change in diagnosis does not affect the benefit period. Regardless of having a new diagnosis or readmission with the same diagnosis, application of benefits is contingent upon the receipt of skilled care in a SNF for a condition which the beneficiary was treated in a qualifying hospital stay. Orientation 2000 Page 3

6 RENEWAL OF BENEFITS IN A SKILLED NURSING FACILITY EXAMPLE 1 SNF 1/10/99 3/15/99 9/1/99 37 benefit days used Occurrence Code 22 No pay discharge claim HOSP Patient cut 3/15/99 Occurrence Code 22 = 3/15/99 on last Part A covered claim Patient remained non-skilled (custodial care) until new hospital admit (9/1/99) No pay discharge bill 3/16/99 9/1/99 4 No special coding on discharge bill Benefit spells will not link New benefit period will be available Orientation 2000 Page 4

7 EXAMPLE 2 SNF 1/10/99 4/18/99 9/1/ benefit days used Benefits Exhausted (A3) Patient exhausts benefits on 4/18/99 No pay discharge claim Patient remains at skilled level of care until new hospital admission (9/1/99) HOSP No pay discharge bill must be submitted (per regulations) to place patient as inpatient from date of service 4/19/99 9/1/99 Spells of illness will link No new benefits will be available to patient EXAMPLE 3 SNF 1/10/99 4/18/99 6/1/99 9/1/ benefit days used Benefits Exhausted (A3) No pay discharge claim HOSP Patient exhausts benefits on 4/18/99 Patient remains at skilled level of care until 6/1/99 No pay discharge bill DOS 4/19/99 10/1/99 may be coded with Occurrence Code 22 = 6/1/99 as long as the patient remained non-skilled for 60 consecutive days beginning 6/1/99 Spells of illness will not link NEW BENEFITS WILL BE AVAILABLE TO PATIENT Orientation 2000 Page 5

8 UB-92 HCFA-1450 (FACSIMILE) PS 2 3 PATIENT CONTROL NO. 4 TYPE OF BILL 6 STATEMENT COVERS 7 COV 8 N-C 9 C-I 10 L-R 11 5 FED. TAX NO. FROM THROUGH D. D. D. D. 12 PATIENT NAME 13 PATIENT ADDRESS 14 BIRTHDATE SEX MS ADMISSION CONDITION CODES DATE 18 HR TYPE 19 SRC D 22 HR STAT 23 MEDICAL RECORD NO OCCURREN 33 OCCURREN 34 OCCURREN 35 OCCURREN 36 OCCURRENCE SPAN 37 CODE CE DATE CODE CE DATE CODE CE DATE CODE CE DATE CODE FROM THROUGH A B C VALUE CODE 40 VALUE 41 VALUE CODE AMOUNT CODE CODES AMOUNT CODE CODES AMOUNT 42 REV.CD. a b c d 43 DESCRIPTION 44 HCPCS/RATES 45 SERV.DATE 46 SERV.UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES REL EST. AMOUNT 50 PAYER 51 PROVIDER NO. ASG INFO BEN 54 PRIOR PAYMENTS DUE INSURED'S NAME 59 P.REL DUE FROM PATIENT 60 CERT.-SSN-HIC.-ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO. 63 TREATMENT AUTHORIZATION CODES 64 ESC 65 EMPLOYER NAME 66 EMPLOYER LOCATION OTHER DIAG. CODES PRIN.DIAG.CD. 68 CODE 69 CODE 70 CODE 71 CODE 72 CODE 73 CODE 74 CODE 75 CODE 76 ADM. DIAG. 77 E-CODE 80PRINCIPAL PROCEDURE 81OTHER PROCEDURE OTHER PROCEDURE 82 ATTENDING PHYS. ID 79 P.C. CODE DATE CODE DATE CODE DATE OTHER PROCEDURE OTHER PROCEDURE OTHER PROCEDURE 83 OTHER PHYS. ID CODE DATE CODE DATE CODE DATE 84 REMARKS OTHER PHY UB-92 HCFA PROVIDER REPRESENTATIVE 86 DATE X I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO TYPE BILL AND ARE MADE A PART Orientation 2000 Page 6

9 SKILLED NURSING FACILITY BILL TYPES SNF Part A Type Span Type of Bill Discharge Status Non-covered Admit Discharge 210 Anything but 30 Covered Admit Discharge 211 Anything but 30 Covered or Non-covered Admit Interim Covered or Non-covered Interim Interim Covered or Non-covered Interim Discharge 214 Anything but Late Charge Bill Part A Services (not permitted under PPS) 217 Adjustment Bill Part A Services 218 Cancel Only Bill Part A Services Ancillary Claims 22X Part B Coverage Only 23X Outpatient Claims Orientation 2000 Page 7

10 SNF PPS 0022 Room and Board Pharmacy IV Therapy Medical/Surgical Supplies Oncology Laboratory Lab-Pathology Radiology Radiology-therapeutic Nuclear Medicine CT Scan Operating Room Services Blood Storage Imaging Services Respiratory Services Physical Therapy Occupational Therapy Speech Therapy Pulmonary Function Audiology Cardiology EKG/ECG EEG Gastro-Intestinal Other Diagnostic Services Other Therapeutic Services ***Ambulance SNF CHARGE STRUCTURE REVENUE CODES 100 All Inclusive 120 Semi-Private (two beds) 13X Semi-Private (three/four beds) 14X Private Room 15X Ward 16X Other (sterile environment) 18X Leave of Absence ( RUGS II Groups) for demonstration SNFs 25X 26X 27X 28X 30X 31X 32X 33X 34X 35X 36X 39X 40X 41X 42X 43X 44X 46X 47X 48X 73X 74X 75X 92X 94X (Complex Medical Equipment) 540 (SNF PPS Facilities) See your UB-92 billing book for value of X in each category 6/98 Orientation 2000 Page 8

11 CODING FOR SKILLED NURSING FACILITIES SNF Discharge Status Required on 21X Bill Types Only Most often used: 01 Discharged to Home 02 Transferred to Hospital (PPS) 03 Transfer to Another SNF 05 Transferred to Non-PPS Hospital 20 Expired 30 Still Patient (Interim Bills 212/213) 50 Discharge to Hospice (Home) 51 Discharge to Hospice (Medical Facility) SNF Condition Codes Most often used: 07 Non-Hospice Related 20 Demand Bill 21 Denial Notice for Other Insurer 39 Private Room Medically Necessary 40 Same Day Transfer 55 SNF Bed Not Available (When patient admission is delayed by 30 days) 56 Medical Appropriateness (When therapy is delayed) 57 SNF Readmission (Patient is readmitted within 30 days) 77 Facility Accepts Other Insurance Payment in Full A6 PPV/Flu Administered (not required) (Plus codes for adjustments. See special listing) Orientation 2000 Page 9

12 SNF Occurrence Codes Most often used: 11 Onset of Illness (Most Recent) 21 UR Notice Received 22 Date Active Care Ended 24 Date Other Insurance Denied 35 Date Treatment Started for Physical Therapy 44 Date Treatment Started for Occupational Therapy 45 Date Treatment Started for Speech Therapy A3 Benefits Exhausted SNF Occurrence Span Codes Most often used: 70 Qualifying Stay 71 Prior Inpatient Stay 74 Non-covered Level of Care * While patient remains in SNF * Show non-covered charges 74 Leave of Absence * While patient is on temporary leave * Do not show non-covered charges 78 Prior SNF Stay M1 Provider Liability on Non-covered Days (Provider Reported) SNF Value Codes Most often used: 09 Medicare Co-insurance 46 Grace Days 50 Physical Therapy Sessions * Cumulative sessions under Part B 51 Occupational Therapy Sessions * Cumulative sessions under Part B 52 Speech Therapy Sessions * Cumulative sessions under Part B Orientation 2000 Page 10

13 ONE DAY STAY Reimbursement for One Day Stays The Medicare Program does not normally reimburse a SNF for date of discharge, death, or when the patient does not meet midnight census criteria. In certain instances, a SNF can be reimbursed for a single day stay if that patient dies or is transferred back to an acute care facility on the day of admission. 1. Coding for same day transfer: Admit date = Through date Patient status = 02 Condition code = 40 Covered days = 1 NOTE: SNF will be reimbursed for one day. Intermediary does not take a SNF benefit day. (Hospital benefit day will be applied). 2. Coding when admit and date of death are the same: Admit date = Through date Patient status = 20 Covered day = 1 NOTE: SNF will be reimbursed for one day. Intermediary does apply one SNF benefit day. Orientation 2000 Page 11

14 NO-PAY DISCHARGE BILLS Medicare requires that skilled nursing facilities (SNFs) submit no pay discharge bills for Part A residents who live in their facilities. Tracking is done by Medicare fiscal intermediaries for the purpose of benefit period management. Because a Medicare beneficiary may have more than one benefit period in a lifetime, it is necessary to account for time lived in hospitals and skilled nursing homes. A new benefit period is available to those individuals who are able to break or end a benefit period by meeting one of the following criteria: 60 consecutive days facility free OR 60 consecutive days living in a SNF at a custodial (non-skilled) level of care The Medicare patient must then have a new qualifying hospital stay of at least 3 days (not counting day of discharge) and be admitted to the SNF within 30 days of hospital discharge. The beneficiary will again be eligible for up to 100 days of Part A SNF coverage if he meets medical criteria. SNFs are required to submit no-pay discharge claims for their residents who are entitled to Part A according to Section 527 of the HCFA Intermediary Manual 12. In the past, has accepted a single no-pay discharge claim for the period of time the beneficiary was not paid under Medicare Part A. With the start of new billing requirements due to the RUGS III Demonstration Project and SNF PPS, no-pay discharge claims MUST be split to reflect the changes in billing methodologies. In addition to all other billing requirements, discharge claims must include: For RUGS III demonstration providers a 9000 revenue code for accommodation charges (FL 42) For SNF PPS providers A line of data using revenue code 0022 (FL 42) A HIPPS code (you may use AAA00) (FL 44) 0 in the units field (FL 46) 0 in the charges field (FL 47) Semi-private accommodation revenue code, rate, units, charges (non-covered) Claims that do not include the special coding requirements will be returned to provider for correction and resubmission. Orientation 2000 Page 12

15 RESUBMITTING COST AVOIDED CLAIMS Providers may submit electronic adjustments for impatient claims that have been cost avoided because records show that another insurance company is responsible for payment of charges. Adjustment claims would be submitted with Type of Bill (TOB) 217. When submitting the electronic adjustment request, use one of the following Condition Codes as appropriate. D7 CHANGE TO MAKE MEDICARE SECONDARY Condition code D7 must be submitted with a MSP Value Code and amount paid by the other insurer must be present on the adjustment claim along with: name and address of the other insurer and employment information (if any). * See MSP section of training manual D8 CHANGE TO MAKE MEDICARE PRIMARY Condition code D8 must be accompanied by remarks indicating the reason that Medicare should pay primary for the dates shown on the rejected claim. Reasons might include: Insurance policy holder has retired. Code claim with Occurrence Code 18 and date (beneficiary) or Occurrence Code 19 and date (spouse) Policy does not cover SNF services. Code claim with Occurrence Code 24 and date other insurance denies Benefits are exhausted under policy. Code claim with Occurrence Code 24 and date policy B/E. MSP files have been updated to show Medicare is primary. Adjustment requests which do not contain sufficient information in the remarks field to demonstrate why Medicare is the primary will be returned to provider (RTP) with the following reason code: Remarks on this adjustment requesting primary payment for an inpatient cost avoided claim are either missing or not sufficient to make primary payment. Orientation 2000 Page 13

16 MAJOR CHANGES FOR BILLING UNDER SNF PPS A new revenue code (0022) has been created to indicate that a RUG-III classification group identifier is being billed on a Part A claim. 4 Revenue code 0022 is to appear on 21X bills for each line of data indicating a RUG-III group code is present 4 Each line of data using revenue code 0022 will be separately calculated for reimbursement based on payment tables in FI pricer software A HIPPS code has been created to indicate the 44 RUG-III groups will be utilized to indicate the medical classification assigned by the grouper program that interprets MDS 2.0 data 4 RUG-III codes are a 3 position alpha code For billing purposes, 19 two position modifiers have been developed and will be added to the RUG-III classification group to indicate what assessment has been completed during the billing period Medicare beneficiaries must be assessed on a specific schedule to determine covered level of care for billing Part A claims Each Medicare assessment provides a specific number of covered days which can be billed for the resident who is determined to be at a skilled level of care All services received by SNF resident must be coded on the Part A claim (no vendor billing) Part B benefits (not covered under the extended care services, i.e., flu shots) are billed separately Orientation 2000 Page 14

17 MDS ASSESSMENT SCHEDULE Medicare Assessment Schedule Assessment Reference Date Reason for Assessment #AA8b MDS 2.0 Users Guide Number of Applicable Medicare Days DAY 5 Comprehensive* May be completed OR at day Medicare 5 Day Assessment 14 Days (1-5) DAY 14 Comprehensive Medicare 14 Day 16 Days (16 30) DAY 30 Full Medicare 30 Day 30 Days (31 60) DAY 60 Full Medicare 60 Day 30 Days (61-90) DAY 90 Full Medicare 90 Day 10 Days (91 100) *If a resident expires or transfers to another facility before day 8, an MDS is prepared as completely as possible allowing for RUG classification and Medicare payment. *Full Assessment = Entire MDS *Comprehensive Assessment = MDS + RAP s Orientation 2000 Page 15

18 MDS 2.0 RUG-III CODES CATEGORY ADL INDEX END SPLITS MDS RUG-III CODES REHABILITATION ULTRA HIGH Rx 720 minutes a week minimum At least 2 disciplines, 1st -5 days, 2nd - at least 3 days RUC RUB RUA VERY HIGH Rx 500 minutes a week minimum At least 1 discipline - 5 days RVC RVB RVA HIGH Rx 325 minutes a week minimum 1 discipline 5 days a week RHC RHB RHA MEDIUM Rx 150 minutes a week minimum 5 days across 1, 2 or 3 disciplines RMC RMB RMA LOW Nrsg. Rehab 6 days in at least 2 activities and Rehabilitation therapy Rx 3 days/ 45 minutes a week minimum RLB RLA EXTENSIVE SERVICES - (if ADL <7, beneficiary classifies to Special Care) IV feeding in the past 7 days (K5a) IV medications in the past 14 days (P1ac) Suctioning in the past 14 days (P1ai) Tracheostomy care in the last 14 days (P1aj) Ventilator/respirator in the last 14 days (P1al) new grouping: count of other categories code into plus IV Meds + Feed SE3 SE2 SE1 SPECIAL CARE -- (if ADL <7 beneficiary classifies to Clinically Complex) Multiple Sclerosis (I1w) and an ADL score of 10 or higher Quadriplegia (Ilz) and an ADL score of 10 or higher Cerebral Palsy (Ils) and an ADL score of 10 or higher Respiratory therapy (P1bdA must = 7 days) Ulcers, pressure or stasis; 2 or more of any stage (M1a,b,c,d) and treatment (M5a, b,c,d,e,g,h) Ulcers, pressure; any stage 3 or 4 (M2a) and treatment (M5a,b,c,d,e,g,h) Radiation therapy (P1ah) Surgical, Wounds (M4g) and treatment (M5f,g,h) Open Lesions (M4c) and treatment (M5f,g,h) Tube Fed (K5b) and Aphasia (I1r) and feeding accounts for at least 51 percent of daily calories (K6a=3 or4) OR at least 26 percent of daily calories and 501cc daily intake (K6b=2,3,4 or 5) Fever (J1h) with Dehydration (J1c), Pneumonia (Ie2),Vomiting (J1o) or Weight loss (K 3a) Fever (J1h) with Tube Feeding (K5b) and, as above, (K6a=3 or 4) &/or (K6b = 2,3,4,or 5) SSC SSB SSA CLINICALLY COMPLEX -- Burns (M4b) Coma (B1) and Not awake (N1 = d) and completely ADL dependent (G1aa, G1ba, G1ha, G1ia = 4 or 8) Septicemia (I2g) Pneumonia (I2e) Foot / Wounds (M6b,c) and treatment (M6f) Internal Bleed (J1j) Dialysis (P1ab) Tube Fed (K5b) and feeding accounts for: at least 51% of daily calories (K6a = 3 or 4) OR 26 percent of daily calories and 501cc daily intake (K6b = 2, 3, 4 or 5) Dehydration (J1c) Oxygen therapy (P1ag) Transfusions (P1ak) Hemiplegia (I1v) and an ADL score or 10 or higher Chemotherapy (P1aa) No. Of Days in last 14 there were Physician Visits and order changes: visits >=1 days and order changes >=4 days; or visits >=2 days and order changes on >=2 days Diabetes mellitus (I1a) and injections on 7 days (O3 >= 7) and order changes >=2 days (P8 >= 2) 17-18D D D 4-11 Signs of Depression Signs of Depression Signs of Depression CC2 CC1 CB2 CB1 CA2 CA1 Orientation 2000 Page 16

19 IMPAIRED COGNITION Score on MDS2.0 Cognitive Performance Scale >= Nursing Rehabilitation* not receiving Nursing Rehabilitation not receiving IB2 IB1 IA2 IA1 BEHAVIOR ONLY Coded on MDS 2.0 items: 4+ days a week - wandering, physical or verbal abuse, inappropriate behavior or resists care; or hallucinations, or delusions checked Nursing Rehabilitation* not receiving Nursing Rehabilitation not receiving BB2 BB1 BA2 BA1 PHYSICAL FUNCTION REDUCED No clinical conditions used Nursing Rehabilitation* not receiving Nursing Rehabilitation not receiving Nursing Rehabilitation not receiving Nursing Rehabilitation PE2 PE1 PD2 PD1 PC2 PC1 PB not receiving Nursing Rehabilitation not receiving PB1 PA2 PA1 Default *To qualify as receiving Nursing Rehabilitation, the rehabilitation must be in at least 2 activities, at least 6 days a week. As defined in the Long Term Care RAI Users Manual, Version 2 activities include: Passive or Active ROM, amputation care, splint or brace assistance and care, training in dressing or grooming, eating or swallowing, transfer, bed mobility or walking, communication, scheduled toileting program or bladder retraining Orientation 2000 Page 17

20 RUG CODES (HIPPS) RUG-III Code Payment Code RUG-III Code Payment Code RUC RUB RUA RVC RVB RVA RHC RHB RHA RMC RMB RMA RLB RLA Rehab Groups RUCXX RUBXX RUAXX RVCXX RVBXX RVAXX RHCXX RHBXX RHAXX RMCXX RMBXX RMAXX RLBXX RLAXX Extensive Care SE3 SE3XX SE2 SE2XX SE1 SE1XX Special Care SSC SSCXX SSB SSBXX SSA SSAXX Impaired Cognition IB2 IB2XX IB1 IB1XX IA2 IA2XX IA1 IA1XX Behavior Only BB2 BB2XX BB1 BB1XX BA2 BA2XX BA1 BA1XX Physical Function Reduced PE2 PE2XX PE1 PE1XX PD2 PD2XX PD1 PD1XX PC2 PC2XX PC1 PC1XX PB2 PB2XX PB1 PB1XX PA2 PA2XX PA1 PA11XX Default AAA00 Clinically Complex CC2 CC2XX CC1 CC1XX CB2 CB2XX CB1 CB1XX CA2 CA2XX CA1 CA1XX Orientation 2000 Page 18

21 HIPPS MODIFIERS/ASSESSMENT TYPE INDICATORS The HIPPS rate codes established by the Health Care Financing Administration (HCFA) contains a 3-position alpha code to represent the RUG-III group medical classification of the SNF resident plus a two position modifier to indicate which assessment was completed. Together they consist of a 5-position HIPPS rate code for the purpose of billing Part A covered days to the fiscal intermediary. Each of the 19 modifiers refers to a specific assessment as explained in the following table. DESCRIPTION OF ASSESSMENT MODIFIER CODE Regular Assessments Admission/Medicare 5 Day Comprehensive 11 Medicare 5 Day (Full) 01 Medicare 14 Day (Full or Comprehensive) 07 Medicare 30 Day (Full) 02 Medicare 60 Day (Full) 03 Medicare 90 Day (Full) 04 Quarterly Review Medicare 90 Day (Full) 54 Significant Change in Status Assessment (SCSA) 38 Other Medicare Required Assessment (OMRA) 08 EXAMPLE: A completed assessment for a SNF resident at day 30 who scores in the RUG-III group SSC would have a HIPPS rate code of SSC02 Significant Correction of Prior Full Assessment Significant Correction of Prior Full 5 Day 41 Significant Correction of Prior Full 14 Day 47 Significant Correction of Prior Full 30 Day 42 Significant Correction of Prior Full 60 Day 43 Significant Correction of Prior Full 90 Day 44 EXAMPLE: Correction to above 30 day assessment example with a new RUG-III group of SEC would have a HIPPS code of = SEC42 Orientation 2000 Page 19

22 DESCRIPTION OF ASSESSMENT MODIFIER CODE OMRA (Replacement) Significant Change in Status Assessment (SCSA) (Replacement) Significant Change in Status Replacing 14 Day 37 Significant Change in Status Replacing 30 Day 32 Significant Change in Status Replacing 60 Day 33 Significant Change in Status Replacing 90 Day 34 EXAMPLE: If a resident experienced a change in medical status outside the regular schedule, a SCSA is required. A SCSA the assessment completed within the window of a regularly scheduled assessment it replaces that assessment. An assessment done on day 27 would replace the 30-day assessment. The HIPPS code for a resident who had a SCSA on day 28 would be SEC32. Default Code: A modifier is required with the use of the default code (AAA) when days are billed on the UB-92 to the Medicare fiscal intermediary for services which are determined to be covered care, but no assessment has been completed to classify the resident. The default modifier is the HIPPS code would appear as AAA 00. Updated 7/98 Orientation 2000 Page 20

23 PART B BENEFITS Who is eligible? Payment can be made under Part B for medical and other health services for inpatients in a SNF if: 1. Part A benefits are exhausted. 2. Part A benefits have been cut. 3. Patient is not enrolled in Part A. 4. Patient does not qualify for Part A coverage because the qualifying hospital stay or transfer requirements were not met. (Patient was admitted from home or admitted more than 30 days from qualifying stay). What services are covered? Part B benefits cover the following services: 1. Diagnostic x-rays, labs, tests (if SNF is hospital based). 2. X-rays, radium and radioactive isotope therapy, including materials and services of technician (If SNF is hospital -based). 3. Surgical dressings, splints, casts, and other devices used for the reduction of fractures and dislocations. 4. Prosthetic devices (other than dental). 5. Leg, arm, back, and neck braces, trusses and artificial legs, arms and eyes (including adjustment and repair and replacement parts). 6. Physical, Occupational and speech therapy; or outpatient speech pathology services. 7. Drugs-limited to PPV, flu, hepatitis B vaccines, oral cancer. 8. Hemophilia clotting factors. 9. Ambulance services.(submit to carrier) Is there any coverage for outpatient SNF patients? Yes, facilities that provide walk-in services at their SNF must have special certification to treat outpatients. In addition to the services mentioned above, the facility may provide and bill for durable medical equipment if it is being provided for residents for use in their homes. NOTE: DME is billed to a special carrier; not to Medicare Part A. Orientation 2000 Page 21

24 What revenue codes are used? 1. For all inclusive ancillary billers Revenue Code 24X (not valid after the start of SNF PPS) 2. Charge structure providers see attached listing How often should Part B services be billed? Part B services should be billed on a monthly basis. It is also allowable to bill quarterly (every 3 months) for all-inclusive providers. Facilities must be very careful not to bill for periods of time in which a person is an inpatient at an acute care hospital. Part B ancillary claims will overlap inpatient claims and require adjustments to correct. Do we have to submit no-pay discharge bills if we are currently billing Part B benefits only? Yes, if you have ever billed Part A services for that patient, unless the last covered day was coded with Occurrence code 22 (and date). If a patient is within their 100 days of Part A benefits, do we also bill separately for the Part B services? No. The Part B services are included in the Part A reimbursement as long as the patient is covered by the Part A benefits. Part B benefits are only billable if the patient is not being covered under Part A. Orientation 2000 Page 22

25 PART B SNF CHARGE STRUCTURE REVENUE CODES DIAGNOSTIC X-RAYS, DIAGNOSTIC LABORATORY TESTS 30X 31X 32X 73X 74X X-RAYS, RADIUM AND RADIOACTIVE ISOTOPE THERAPY (including materials and services of technicians): 33X 34X 35X MEDICAL AND SURGICAL SUPPLIES AND DEVICES 27X PROSTHETIC DEVICES (other than dental) which replace all or part of an internal body organ (including contiguous tissue) or all or part of the function of the permanently inoperable or malfunctioning internal body organ, including replacement or repairs of such items 274 * PHYSICAL THERAPY 42X* OCCUPATIONAL THERAPY 43X* SPEECH THERAPY 44X* SPECIALTY DRUGS 63X * (PPV, FLU, HEP B, Immunosuppressive Drugs, Hemophelia Clotting, Oral Cancer and anti-emetic drugs) * Requires HPCPS NOTE: Lab and X-ray services may only be billed if you have certified units within your facility Until Part B Consolidated Billing is in effect, vendors may continue to bill directly for their services to the carrier, and outpatient hospitals may bill services directly to the fiscal intermediary. Orientation 2000 Page 23

26 SNF BILLING HCPCS CODING REQUIREMENTS There are no HCPCS codes required on Medicare Part A claims. In the realm of Part B billing, the requirements differ from inpatient billing (bill types 221 and 223) to outpatient billing (bill types 231 and 233). For inpatient Part B billing, HCPCS codes are required on the following revenue codes: 274 prosthetic/orthotic devices 420 physical therapy * 430 occupational therapy * 440 speech therapy * 636 drugs requiring detailed coding (PPV, flu, etc.) 771 administration of a drug (used when 636 is billed) * See Medicare News Update , , Effective for dates of service 7/1/98 HCPCS are required for therapy services on Part B claims. Effective with consolidated billing HCPCS will be required for all Part B services. For outpatient Part B billing, HCPCS codes are required on the following revenue codes: 30X all lab revenue codes 31X all lab path revenue codes 320 angiocardiography 323 arteriography 274 prosthetic/orthotic devices 636 drugs requiring detailed coding (PPV, flu, etc.) *See Medicare News Update , uses the St. Anthony's Level II Code Book for HCPCS reference. If your billers select a code from their reference source, the validity of this code can be checked using the OmniPro system. As is the case for diagnosis and revenue codes, the OmniPro files will mirror our internal computer (Fiscal Intermediary Shared System) and allow the biller to determine if the selected code will be accepted during claims processing. Orientation 2000 Page 24

27 BILLING THERAPY SERVICES UNDER PART B IN A SNF Physical, occupational and speech therapy are billable to the Medicare fiscal intermediary (FI) if those services are deemed to be restorative in nature by Medicare definition. (See sections 220, 230.3, 542 of HIM-12) Coding Requirements on the UB-92 ONSET OF ILLNESS Occurrence Code 11 and date are required on Part B claims (they are not required on Part A claims) If the Part B services are a continuation of therapy begun when the resident was first admitted to the SNF (under Part A) the onset of illness date should reflect this. If you do not know when the patient became ill or was injured (prior to admission) you may use the SNF admission date for the Occurrence Code 11 date If the Part B services are based on new injury or illness (not associated with a SNF Part A admission), determine the date for Occurrence Code 11 based on when it was noted in the patient's medical record that there has been a change in condition requiring a restorative therapy program. START DATE OF THERAPY Occurrence Code 35 for physical therapy (PT), 44 for occupational therapy (OT), and 45 for speech therapy (ST) and date are required on Part B claims If the Part B services are a continuation of therapy that began under Part A, the start date for therapy would be when services were originally initiated under Part A. If the Part B services are not associated with Part A services, the start date would be the first services rendered after the patient was noted to have had a change in condition requiring a restorative therapy program. Orientation 2000 Page 25

28 PART B THERAPY BILLING Type of Bill 12X 13X 22X 23X 74X 75X 83X Hospital inpatient ancillary Hospital outpatient SNF inpatient ancillary SNF outpatient ORF (Outpatient Rehabilitation Facility) CORF (Comprehensive Outpatient Rehabilitation Facility) Ambulatory surgery center Billing Frequency Repetitive services, such as PT, OT, and SLP, must be billed on a monthly basis and not on a visit by visit basis. Revenue Codes Primary Diagnosis 420 Physical Therapy 430 Occupational Therapy 440 Speech-language Pathology The primary diagnosis on the claim should be the diagnosis for which the patient is receiving therapy services. Occurrence Codes Occurrence codes and associated dates define a significant event relating to the bill that may affect processing. The following occurrence codes need to be used by all outpatient therapy providers: 11 Date of onset of symptoms or illness which resulted in the patient s current need for the therapy. This code must be present on all physical, occupational and speech therapy and CORF claims. It should not change during the episode of care unless the patient has a new onset or exacerbation of an illness. 35 Date of initial P T service at provider 44 Date of initial OT service at provider 45 Date of initial SLP service at provider O R F s also use the following occurrence codes: 17 Date OT treatment plan was established or last reviewed 29 Date P T treatment plan was established or last reviewed 30 Date SLP treatment plan was established or last reviewed Orientation 2000 Page 26

29 C O R F s use: 28 Date CORF treatment plan was established or last reviewed. Value Codes A value code is a code that relates amounts or values to specific data elements. Right justify the whole number therapy visit amount to the left of the dollar/cents delimiter and zero fill the cents field. The following value codes need to be used when billing therapy services: 50 Number of PT visits from the start of care at the billing provider through the current billing period 51 Number of OT visits from the start of care at the billing provider through the current billing period 52 Number of S L P visits at the billing provider from the start of care through the current billing period EXAMPLE: If the patient had 10 physical therapy visits in the first billing period, and20 physical therapy visits in the second billing period, the cumulative number of physical therapy visits would be 30, this would be shown on the claim as value code: 50 Health Care Financing Administration Common Procedure Coding System (HCPCS) HCPCS codes are comprised of two levels. Level I contains the American Medical Association's (AMA) Physicians' Current Procedural Terminology, Fourth Edition (CPT- 4) codes. These consist of all numeric codes. Level II contains the codes for physician and non-physician services that are not included in CPT-4, e.g., ambulance, durable medical equipment (DME), orthotics, and prosthetics. These are alpha/numeric codes maintained jointly by the Health Care Financing Administration (HCFA), the Blue Cross and Blue Shield Association (BCBSA), and the Health Insurance Association of America (HIAA). Providers rendering outpatient therapy services are required to submit claims with HCPCS codes for dates of service on or after April 1, A grace period was allowed until July 1, 1998 dates of service. HCPCS codes for reporting outpatient physical, occupational, and speech therapy include the following: 11040* 29105* * * 29125* * * 29126* 29345* 29540* * 29130* 29365* 29550* * * 29580* * 29200* 29445* 29590* Orientation 2000 Page 27

30 29075* * * *** V ** 97250** ** G0169**** ** V ** V5363 *These codes apply in all settings (bill types 12X, 22X, 23X, 74X, and 75X), except hospital outpatient departments (bill types 13X and 83X). When delivered in hospital outpatient settings, these services are not considered rehabilitation services and will not be subject to the outpatient rehabilitation prospective payment system. **1998 codes ***97504 should not be billed with ****G0169 is a new code for These codes are the ones commonly utilized for outpatient rehabilitation services. Other codes may be considered for payment if they are determined to be medically necessary and are performed within the scope of practice of the therapist rendering the service. Inclusion of a HCPCS code on this list does not assure coverage of a specific service. Current coverage criteria still apply. SELECTING HCPCS CODES Use the HCPCS code available that best describes the service rendered. There is not a specific code available for every service, e.g., transfer training. Use unlisted HCPCS code only when absolutely necessary. A description of what is being billed under the unlisted code must be put in the remarks field of the claim. HCPCS 97010, 97545, and are considered bundled charges and should not be billed on Medicare claims. EVALUATIONS Evaluation HCPCS codes are inclusive of all procedures needed to evaluate the patient. Initial evaluations can be billed when there is an expectation that the patient will require covered therapy services. Re-evaluations can be billed when the patient exhibits a demonstrable change in physical functional ability necessitating revised treatment goals. Monthly reevaluations/assessments for a patient undergoing restorative SLP programs are considered part of the treatment session and are not separately billable. Orientation 2000 Page 28

31 UNITS OF SERVICE Units of service are based on the number of times the procedure, as defined by the HCPCS code, is performed. If the HCPCS code has a time definition, the units are based on a multiple of that time factor. If more than one type of treatment is rendered that fit the same HCPCS, add all of the time together for these treatments before figuring units. If the HCPCS code is not defined by a specific time frame, report one unit. To bill more than one unit there must be a physician order/certification that the therapy session should be rendered more than once daily. It must be reasonable and necessary for the patient s condition, and it must be reflected on the plan of treatment. Only whole numbers are used for units. EXAMPLES A. A patient receives OT, HCPCS code for 60 minutes is therapeutic activities, direct (one on one) patient contact by the provider (use of dynamic activities to improve functional performance) each 15 minutes REPORT: Revenue Code HCPCS/Rate Service Unit B. A patient receives ST, HCPCS code for 30 minutes is treatment of swallowing dysfunction and/or oral function for feeding REPORT: Revenue Code HCPCS/Rate Service Unit C. A patient receives PT, HCPCS code for 10 minutes is therapeutic procedure, one or more areas, each 15 minute gait training (includes stair climbing) REPORT: Revenue Code HCPCS/Rate Service Unit CPT codes and descriptions only are copyright 1998 American Medical Association (or such other date publication of CPT). Line Item Dates of Service Line item dates of service must be reported beginning with services provided on October 1, Orientation 2000 Page 29

32 Discipline Specific Modifiers Providers are required to report the following modifiers to distinguish the type of therapist who performed the outpatient rehabilitation service. If the service was not delivered by a therapist, then the discipline of the plan of treatment under which the service is delivered should be reported. Modifiers are added to the end of the HCPCS code. GN Speech-language pathologist or under SLP plan of treatment GO Occupational therapist or under OT plan of treatment GP Physical therapist or under PT plan of treatment EXAMPLE: Therapeutic activities rendered by a Certified Occupational Therapist Assistant (COTA) would be billed: GO Billing for Prior Dates of Service DATES OF SERVICE 10/01/97 THROUGH 4/01/98 HOSPITALS ONLY Beginning with dates of 10/01/97, hospitals were required to use HCPCS codes for outpatient physical and occupational therapy services. The following HCPCS codes were used. PT Evaluation Q0103 for dates of service 10/01/97 12/31/ for dates of service beginning 1/1/98 PT Re-evaluation Q0104 for dates of service 10/01/97 12/31/ for dates of service beginning 1/01/98 PT Treatments OT Evaluation Q0109 for dates of service 10/01/97 12/31/ for dates of service beginning 1/1/98 OT Re-evaluation Q0110 for dates of service 10/01/97 12/31/ for dates of service beginning 1/01/98 OT Treatments Units of service: Each HCPCS code was counted as one unit per day regardless of the length of time performed or time element in the HCPCS description. DATES OF SERVICE PRIOR TO 4/01/98 (PRIOR TO 10/01/97 FOR HOSPITALS) Prior to 10/01/97 for hospitals and prior to 4/01/98 for SNF, ORF, and CORF, therapy was billed on a visit basis. Under this system, each therapy visit was counted as one unit no matter how many treatments were done during that visit. No HCPCS codes were required. Orientation 2000 Page 30

33 Notes Orientation 2000