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Skilled Nursing Facility Billing Reference

What’s Changed?

We clarified how to use place of service (POS) codes codes 21, 31, and 32.

Substantive content changes are in dark red.

Skilled Nursing Facility Stays

Part A covers Medicare-certified skilled nursing facility (SNF) skilled care. Skilled care is nursing or other rehabilitative services, provided according to physician orders, that:

  • Require skills of qualified technical or professional health personnel, like:
    • Registered nurses
    • Licensed practical or vocational nurses
    • Physical therapists
    • Occupational therapists
    • Speech-language pathologists or audiologists
  • Skilled nursing or skilled rehabilitation personnel, or others under their general supervision, provide:
    • General supervision that requires initial direction and periodic inspection of the actual activity
    • Services that an assistant performs when a supervisor isn’t always physically present or at the location

We consider a service skilled if, because of its inherent complexity, you can only perform it safely and effectively by, or under the general supervision of, skilled nursing or skilled rehabilitation personnel.

Original Medicare enrollees must meet these conditions to qualify for Part A-covered SNF services:

  • Patient was a hospital inpatient for a medically necessary stay of at least 3 consecutive calendar days
    • Time spent in observation or in an emergency room doesn’t count toward a medically necessary 3-day qualifying inpatient hospital stay
    • A Medicare Advantage (MA) plan, 1876 Cost plan, or Program of All-inclusive Care for the Elderly (PACE) plan may waive the 3-day stay for enrollees
  • Patient transfers to Medicare-certified SNF within 30 days after hospital discharge, unless both are true:
    • Patient’s condition makes it medically inappropriate to start active treatment in a SNF immediately after discharge
    • It’s medically predictable at patient’s hospital discharge that they’ll need covered SNF care within a predetermined period (generally no more than 30 days), and they meet that prediction
  • Patient needs daily skilled nursing or rehabilitation services

Daily skilled services can happen only in a SNF on an inpatient basis if:

  • They aren’t available on an outpatient basis in the patient’s location
  • When compared to an inpatient setting, transportation to a facility is:
    • Excessive physical hardship
    • Less economical
    • Less efficient or effective
  • Services are reasonable and necessary for diagnosing or treating a patient’s qualifying condition and of reasonable duration and quantity

3-Day Prior Hospitalization

A patient meets the 3-consecutive-day stay requirement by staying 3 consecutive days in 1 or more hospitals. Only the admission day, not the discharge day, counts as a hospital inpatient day. Time spent in observation or in the emergency room before admission doesn’t count toward the 3-day qualifying inpatient hospital stay.

3-Day Stay Waiver

Certain SNFs that have a relationship with Shared Savings Program (SSP) Accountable Care Organizations (ACOs) may waive the SNF 3-day rule. Occasionally, during a Public Health Emergency, we may issue a temporary waiver. Most MA plans waive the 3-day hospitalization requirement.

MA plans, 1876 Cost plans, or PACE plans typically waive the 3-day hospitalization requirement. MA plans must cover the same number of SNF days Original Medicare covers, but they may cover more.

Note: For MA plan patients, check with the MA plan for information on eligibility, coverage, and payment. Each plan can have different patient out-of-pocket costs and specific rules for getting and billing for services.

You must follow the plan’s payment terms and conditions:

  • MA plans may offer different benefit periods.
  • Each MA plan’s Evidence of Coverage (EOC) describes all its benefits, including SNF coverage.
  • Most MA plans offer SNF coverage through network providers paid according to their contracts. Non-network SNFs should confirm MA coverage with the enrollee’s MA plan.
  • MA plans that cover SNF services provided by non-network SNFs pay the Original Medicare payment rate, consistent with MA regulations at 42 CFR 422.214.
  • For each benefit period, Part A covers up to 20 full days of care. After that, Part A covers up to an additional 80 days, with the patient paying coinsurance for each day.
  • After 100 days, the SNF coverage available during that benefit period exhausts, and the patient pays for all care, except certain Medicare Part B services.

Your Medicare Benefits has more information about patient coverage, costs, and care in a SNF.

  • We measure SNF coverage in benefit periods, sometimes called “spells of illness.” It starts the day a hospital or SNF admits a patient as an inpatient.
  • A benefit period ends after a hospital discharges a patient or a patient has had 60 consecutive days of SNF skilled care.
  • Once a benefit period ends, a new benefit period starts when a hospital or SNF admits a patient. New benefit periods don’t start with a change in diagnosis, condition, or CY.
  • SNFs must understand benefit periods because sometimes they must submit claims even when they don’t expect payment. This ensures proper benefit period tracking in the Common Working File (CWF). The Special Billing Situations section has more information

The Common Working File…

…tracks SNF benefit periods and patient information that Medicare Administrative Contractor (MAC) claims processing systems use to ensure proper payments.

This figure describes the relationships between coverage, skilled care, the benefit period, and type of claim, if any, to submit to us:

SNF Coverage & Billing Summary

Providers should communicate with patients about:

  • Whether SNF care is right for them — Medicare skilled care can manage the patient’s current condition to prevent or slow further deterioration.
  • SNF coverage requirements — Determine if the patient meets SNF coverage requirements before ordering SNF care. If the SNF care isn’t medically reasonable and necessary, or is considered custodial care, Part A won’t cover the SNF care.

Skilled Nursing Facility Part B Billing

You must bill some services to Part B. Bill repetitive services to Part B monthly or when treatment stops. Bill one-time services to Part B when you complete the service. Medicare Claims Processing Manual, Chapter 7 has more information.

Payment

We pay for SNF services per diem under a Prospective Payment System (PPS). The SNF PPS per diem payment covers all Part A SNF services (routine, ancillary, and capital-related costs), except operating-approved educational activities and services excluded from SNF Consolidated Billing (CB) costs under Section 1888(e)(4)(E) of the Social Security Act.

We base Part A payment primarily on the patient’s assigned case-mix classification. We use the ICD-10-CM codes on the Minimum Data Set (MDS) in Item I0020B and map these codes to a Patient Driven Payment Model (PDPM) clinical category.

PDPM helps decide payment by classifying SNF patients in covered Part A stays. It affects PPS payments by:

  • Improving payment accuracy by focusing on patient characteristics rather than number of services provided
  • Reducing administrative provider burdens
  • Improving SNF payments to underserved patients without increasing our total payments

PDPM website has more information.

General Payment Tips


  • We won’t pay under the SNF PPS unless you bill a covered day
  • We only allow ancillary charges for covered days and those included in the PPS rate

We bundle payment for most patient services in a covered Part A SNF stay, including most services provided by entities other than the SNF. SNFs must bill these bundled services to their MAC in a CB. If you or your entity delivered services subject to CB and aren’t the SNF, don’t bill Medicare; bill the SNF.

Consolidated Billing Resources

SNF Consolidated Billing webpage and the SNF Consolidated Billing web-based training have more information.

When we disqualify a patient’s SNF Part A coverage, CB rules don’t apply. The following situations are reasons for disqualification:

  • Part A benefits exhaust
  • No qualifying 3-day hospital stay
  • Level-of-care requirement not met

There’s no comprehensive institutional coverage like under Part A for a non-covered Part B stay. However, the patient may qualify for Part B medical coverage and other individual health services.

We may pay for:

  • Outpatient hospital services to patients who aren’t SNF inpatients:
    • Diagnostic tests like diagnostic X-rays or lab tests
    • Physical Therapy (PT), Occupational Therapy (OT), or Speech-Language Pathology (SLP) services
    • Physician and surgeon services
  • Services excluded from SNF PPS and SNF CB
  • Certain medical and other health services to patients residing in a SNF whose Part A benefits exhausted or who aren’t otherwise entitled to Part A payment
 

Billing Requirements

SNFs bill Part A using CMS-1450, also called UB-04, or its electronic equivalent. Send claims monthly, in order, and when the patient:

  • Drops from skilled care
  • Discharges
  • Exhausts benefit period

When a patient’s benefits exhaust, follow the guidance in Table 3 to make sure the claims processing system accurately tracks the benefit period.

Medicare Claims Processing Manual, Chapter 25 has CMS-1450 general billing information. SNFs must also populate the Table 1 elements for Part A claims. You need to fill out these fields for all claims.

Table 1. SNF Billing Requirements
UB-04 Field Report

FL 04

Type of Bill (TOB)

21X for SNF inpatient services.

18X for hospital swing bed services.

FL 06

Statement Covers Period (From and Through dates)

From date must be the admission date or, for a continuing stay bill, the day after the Through date on the prior bill.

Through date is the last day of the billing period.

FL 31–FL 34

Occurrence Code and Date

 50 with the Assessment Reference Date (ARD) for each assessment period on the claim with Revenue Code 0022. You don’t need occurrence code 50 for the default Health Insurance Prospective Payment System (HIPPS) code.

FL 35 & FL 36

Occurrence Span Code (From and Through dates)

 70 with the dates of the 3-consecutive-day qualifying stay.

FL 42

Revenue Code

 0022 to show you’re submitting the claim under the SNF PPS. You can use this revenue code as often as necessary to show different HIPPS rate codes and assessment periods.

FL 44

HCPCS/Rate/HIPPS Code

HIPPS rate code (SNF billing practices related to HIPPS codes stay the same under PDPM).

Must be in the same order the patient got that level of care. Certain HIPPS rate codes need more rehabilitation therapy ancillary revenue codes. If you don’t include the corresponding codes, your MAC returns the claims for re-submission.

FL 46

Units of Service

 Number of covered days for each HIPPS rate code.

FL 47

Total Charges

 Zero for 0022 revenue code lines.

FL 67

Principal Diagnosis Code

 ICD-10-CM code for the principal diagnosis.

FL 67A–FL 67Q

Other Diagnoses

 ICD-10-CM codes for up to 8 other conditions.

Section 30 of the Medicare Claims Processing Manual, Chapter 6 has a full explanation of required assessments.

  • Bill in order. MACs return a continuing stay bill if the prior bill hasn’t processed. If you submitted the prior bill, hold the returned continuing stay bill until you get the Remittance Advice (RA) for the prior bill.
  • Don’t count the day of discharge or death, or a day when a patient starts a Leave of Absence (LOA), as a utilization day.
  • If a facility discharges a patient who returns before the following midnight, we don’t count it as a discharge.
  • HIPPS rate code appearing on the claim must match the assessment submitted and accepted by CMS’ national database, the iQIES system. HIPPS Codes webpage has more information.

For help with other billing situations, find your MAC’s website.

Place of service (POS) codes identify where a patient gets a service. Enter the correct 2-digit code on Medicare claims to ensure proper payment for physician services provided to patients in inpatient facilities like SNFs and hospitals. POS codes frequently associated with SNF extended care services include:

  • Inpatient hospital: 21
  • SNF (with Part A coverage): 31
  • Nursing facility (or SNF with no Part A coverage): 32

For example, if a patient is seen in a physician’s office but is also:

  • An inpatient of a hospital, use POS code 21 for inpatient hospital
  • A patient of a SNF (with Part A), use POS code 31 for SNF
  • A patient of a nursing facility or SNF without Part A, use POS code 32 for nursing facility

The POS code reflects a different setting than the address and ZIP Code of the practice location.

Certain situations require deviations from the billing practices we discussed above. In these cases, you must submit a no-pay claim even though you don’t expect payment. The information in Tables 2–7 helps you decide how to bill various Part A situations. Remember, you must supply adequate claims-supporting documentation for reported services.

Re-admission happens when the SNF discharges and re-admits a patient for skilled care within 30 days after the discharge day. This patient can resume using available SNF benefit days without another qualifying hospital stay. The same is true if the patient stays in the SNF for custodial care after a covered stay, then develops a new skilled care need within 30 consecutive days after the first day of non-coverage.

Table 2. Re-admitted Within 30 Days After Discharge Situations
If… Then…
You sent a discharge claim before re-admission

Submit another bill and report:

  • Current stay admission date
  • Condition Code 57
  • Occurrence Span Code 70 with the qualifying hospital stay dates of at least 3 days
You re-admit a patient before you send a discharge claim

Submit an interim bill and report:

  • Current stay admission date
  • Condition Code 57
  • Occurrence Span Code 70 with the qualifying hospital stay dates of at least 3 days
  • Occurrence Span Code 74 showing the LOA From and Through dates and the number of non-covered days

When benefits exhaust, continue submitting monthly bills if the patient stays in a Medicare-certified area of the facility. Benefits can exhaust:

  • Fully — Patient had no benefit days available between the From and Through dates on the claim
  • Partially — Patient had benefit days available between the From and Through dates on the claim
Table 3. Benefits Exhaust Situations
If… Then…
Patient moves to a non-Medicare-certified area of the institution

Discharge them using the correct discharge status code.

If appropriate, the claims processing system applies an A3 Occurrence Code with the last day the patient had benefits.

Report:

  • Covered TOB except for 210 or 180
  • HIPPS ZZZZZ
  • Occurrence Span Code 70 with qualifying hospital stay dates
  • All covered days and charges = submit all covered days and charges as if patient had days available
  • Value Code 09 (first year coinsurance amount) = $1
  • Patient Status Code

Don’t submit Part B services with TOB 22X until the benefits exhaust claim processes. Submit Part B services delivered after skilled care ended, including therapy, on a TOB 22X.
Patient drops to a non-skilled level of care while benefits exhaust and stays in a Medicare-certified area of the institution

Report:

  • TOB 212 or 213 for SNF and 182 or 183 for Swing Bed; don’t report TOBs 210 or 180
  • Occurrence Span Code 70 with qualifying hospital stay dates
  • Occurrence Code 22 with date covered SNF care ended
  • Value Code 09 (first year coinsurance amount) = $1
  • Patient Status Code 30

Submit Part B services delivered after skilled care ended, including therapy, on a TOB 22X.
Patient drops to a non-skilled level of care while benefits exhaust and moves to a non-Medicare-certified area of the institution or otherwise discharges

Report:

  • TOB 211 or 214 for SNF and 181 or 184 for Swing Bed; don’t report 210 or 180
  • All covered days and charges = submit all covered days and charges as if patient had days available
  • Value Code 09 (first year coinsurance amount) = $1
  • Patient Status Code, other than 30

Submit Part B services delivered after skilled care ended, including therapy, on a TOB 23X.

For no-payment billing, the patient drops to a non-skilled level of care and stays in a Medicare-certified area of the institution.

Table 4. No-Payment Billing Situations
If… Then…
You need a denial notice so another insurer will pay, send the initial no-payment claim with the From date as the date SNF care ended. Then, continue to send claims as often as monthly.

Report:

  • TOB 210 for SNFs or 180 for Swing Beds
  • All days and charges as non-covered, starting the day following the day SNF care ended
  • Condition Code 21
  • Patient Status Code
  • HIPPS ZZZZZ

Submit Part B services delivered after skilled care ended, including therapy, on a TOB 22X.
No denial notice is needed, send 1 final discharge claim. The claim may span both the SNF and Medicare FY end dates.

Report:

  • TOB 210 for SNFs or 180 for Swing Beds
  • From date as the day SNF care ended
  • Through date as the discharge date
  • All days and charges as non-covered, starting the day following the day SNF care ended
  • Condition Code 21
  • Patient Status Code (other than 30)
  • HIPPS ZZZZZ

Submit Part B services delivered after skilled care ended, including therapy, on a TOB 22X.

Provider-initiated discharges for coverage reasons associated with SNF and inpatient swing bed claims need an expedited determination notice. A patient or a representative can appeal provider service terminations to a Quality Improvement Organization (QIO) through the Expedited Determinations process.

QIOs must inform the patient of:

  • Their right to an expedited reconsideration by the Qualified Independent Contractor (QIC)
  • How to ask for an expedited reconsideration

You must report the outcomes of expedited determinations on the claim.

Table 5. Expedited Review Results Situations
If… Then…
QIO or QIC upholds the discharge decision

Report:

  • Discharge for billing period that precedes determination
  • Condition Code C4
  • If the patient’s liable for care days, report:
    • Occurrence Span Code 76 with the days the patient incurred liability
    • Zero charges for the patient-liable days
    • Modifier –TS for HCPCS codes for those days
QIO or QIC authorizes continued coverage with no specific end date

Report:

  • Continuing claim for the current billing or certification period
  • Condition Code C7
QIO or QIC authorizes continued coverage only for a limited period, and the time extends beyond the end of the normal billing or certification period

Report:

  • Continuing claim for the current billing or certification period
  • Condition Code C3
  • Occurrence Span Code M0 with the starting date of QIO- or QIC-approved coverage and the claim Through date
QIO or QIC authorizes continued coverage only for a limited period, and the time doesn’t extend beyond the end of the normal billing or certification period

Report:

  • Discharge claim
  • Condition Code C3
  • Occurrence Span Code M0 with the starting and end dates of QIO- or QIC-approved coverage
Provider is liable due to failure to give information promptly to the QIO or QIC or deliver valid notice to the patient Report services as non-covered with modifier –GZ.

The patient doesn’t meet Medicare SNF coverage requirements.

Table 6. Non-Covered Days Situations
If… Then…
Patient is liable

Report Occurrence Span Code 76.

Submit the claim as covered if care is skilled.
SNF is liable

Report Occurrence Span Code 77.

Submit the claim as covered if care is skilled.
Table 7. Other SNF Billing Situations
Situation If… Then…
No Qualifying Hospital Stay Facility admits a patient who needs skilled care but doesn’t have a qualifying hospital stay. This includes patients initially admitted as skilled, following a qualifying hospital stay, who then dropped to a non-skilled level of care for more than 30 days. This ended their connection to the original qualifying hospital stay, but the patient became skilled again without a new qualifying hospital stay. Bill normally, but don’t report Occurrence Span Code 70.
Same Day Transfer SNF admits a patient who’s expected to stay overnight but transfers before the following midnight to a Medicare-participating facility.

Report:

  • Same admission From and Through dates
  • Zero covered days
  • Condition Code 40
Leave of Absence (LOA) Patient leaves the SNF but isn’t admitted as an inpatient to any other facility.

Report:

  • Revenue Code 018X
  • Number of LOA days as units
  • Zero charges
  • Occurrence Span Code 74 showing From and Through dates for the LOA and the number of non-covered days
Forced Discharge Patient leaves the SNF, and another facility admits the patient as an inpatient. Bill as a discharge. If the SNF re-admits the patient within 30 days, follow the instructions in Table 2.
Non-Skilled Discharge Patient drops to a non-skilled level of care and moves to a non-Medicare-certified area of the institution. Discharge the patient on a final discharge claim. Submit services provided after discharge on TOB 23X.
Demand Billing SNF believes covered skilled care is no longer medically necessary, and the patient disagrees.

Report:

  • Condition Code 20
  • Occurrence Code 22 with the date SNF care ended or Occurrence Code 21 with the date you got the utilization review notice
Medicare Advantage (MA) Plan Information-Only Billing Patient is an MA plan enrollee.

Submit information-only claims to Medicare so the Common Working File (CWF) can track the benefit period.

Report:

  • HIPPS code based on assessment or HIPPS ZZZZZ if no assessment happened
  • Room and board charges
  • Condition Code 04
Disenroll From MA Plan and Enroll in FFS While SNF Inpatient Patient meets the level of care criteria through the effective disenrollment date.

We waive the qualifying hospital stay requirement and the patient is eligible for the number of days left out of the 100-day benefit period for that stay minus the days Original Medicare would’ve covered while the patient was an MA plan enrollee.

Report Condition Code 58.
Disenroll From MA Plan after SNF Discharge and Enroll in FFS Facility re-admits a patient under 30-day rule.

Patient must meet all FFS requirements, including qualifying 3-day hospital stay. Providers may charge patients SNF coinsurance.

Report Condition Code 58.
Disenroll From MA Plan Patient disenrolls from MA Plan before SNF admission.

Patient must meet all requirements for FFS, including qualifying 3-day hospital stay.

Report Condition Code 58.
Interrupted Stay Patient is discharged from a Part A-covered stay and then resumes SNF care in the same SNF for a Part A-covered stay during a 3-day period, starting with the calendar day of Part A discharge and including the 2 calendar days immediately following (known as an interruption window). We require an Omnibus Budget Reconciliation Act (OBRA) Discharge Assessment. We require an entry tracking record on re-entry, but not a 5-day MDS assessment.

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