Billing in Benefits Exhaust and No-Payment Situations

40.8 - Billing in Benefits Exhaust and No-Payment Situations (Rev. 4491, Issued: 01-09- 20, Effective: 04-01-20, Implementation: 04-06-20) An SNF is required to submit a bill for a beneficiary that has started a spell of illness under the SNF Part A benefit for every month of the related stay even though no benefits may be payable. CMS maintains a record of all inpatient services for each beneficiary, whether covered or not. The related information is used for national healthcare planning and also enables CMS to keep track of the beneficiary’s benefit period. These bills have been required in two situations: 1) when the beneficiary has exhausted his/her 100 covered days under the Medicare SNF benefit (referred to below as benefits exhaust bills) and 2) when the beneficiary no longer needs a Medicare covered level of care (referred to below as no-payment bills). For benefits exhaust bills, an SNF must submit monthly a benefits exhaust bill for those patients that continue to receive skilled care and also when there is a change in the level of care regardless of whether the benefits exhaust bill will be paid by Medicaid, a supplemental insure, or private payer. There are two types of benefits exhaust claims: 1) Full benefits exhaust claims: no benefit days remain in the beneficiary’s applicable benefit period for the submitted statement covers from/through date of the claim and 2) Partial benefits exhaust claims: only one or some benefit days, in the beneficiary’s applicable benefit period, remain for the submitted statement covers from/through date of the claim. Monthly claim submission of both types of benefits exhaust bills are required in order to extend the beneficiary’s applicable benefit period posted in the Common Working File (CWF). Furthermore, when a change in level of care occurs after exhaustion of a beneficiary’s covered days of care, the provider must submit the benefits exhaust bill in the next billing cycle indicating that active care has ended for the beneficiary. NOTE: Part B 22x bill types must be submitted after the benefits exhaust claim has been submitted and processed. In addition, SNF providers must submit no-payment bills for beneficiaries that have previously received Medicare-covered skilled care and subsequently dropped to a non- covered level of care but continue to reside in a Medicare-certified area of the facility. Consolidated Billing (CB) legislation indicates that physical therapy, occupational therapy, and speech language pathology services furnished to SNF residents are always subject to SNF CB. This applies even when a resident receives the therapy during a non-covered stay in which the beneficiary who is not eligible for Part A extended care benefit still resides in an institution (or part thereof) that is Medicare- certified as a SNF. SNF CB edits require the SNF to bill for these services on a 22x (inpatient part B) bill type. NOTE: Unlike with benefits exhaust claims, Part B 22x bill types may be submitted prior to the submission of bill type 210 no payment claims. If a facility has a separate, distinct non-skilled area or wing then beneficiaries may be discharged to this area using the appropriate patient discharge status code and no- payment bills would not be required. In addition, SNF CB legislation for therapy services would not apply for these beneficiaries. No-payment bills are not required for non-skilled beneficiary admissions. As indicated above, they are only required for beneficiaries that have previously received covered care and subsequently dropped to non-covered care and continue to reside in the certified area of the facility. NOTE: Providers may bill benefits exhaust and no payment claims using the default HIPPS code AAA00 prior to October 1, 2019 and ZZZZZ October 1, 2019 and after, in addition to an appropriate room & board revenue code only. No further ancillary services need be billed on these claims. SNF providers and A/B MACs (A) shall follow the billing guidance provided below for the proper billing of benefits exhaust bills and no-payment bills. 1) SNF providers shall submit benefits exhaust claims for those beneficiaries that continue to receive skilled services as follows: a) Full or partial benefits exhaust claim. (Submitted monthly) i) Bill Type = Use appropriate covered bill type (i.e., 211, 212, 213 or 214 for SNF and 181, 182, 183 or 184 for Swing Bed (SB). NOTE: Bill types 210 or 180 should not be used for benefits exhaust claims submission). ii) Occurrence Span Code 70 with the qualifying hospital stay dates. iii) Covered Days and Charges = Submit all covered days and charges as if beneficiary had days available. iv) Value Code 09 (First year coinsurance amount) 1.00 (If applicable, the FISS will assign the correct coinsurance amount based off the CWF response). v) Patient Status Code = Use appropriate code. b) Benefits exhaust claim with a drop in level of care within the month; Patient remains in the Medicare-certified area of the facility after the drop in level of care. i) Bill Type = Use appropriate bill type (i.e., 212 or 213 for SNF and 182 or 183 for SB. NOTE: Bill types 210 or 180 should not be used for benefits exhaust claims submission). ii) Occurrence Span Code 70 with the qualifying hospital stay dates. iii) Occurrence Code 22 (date active care ended, i.e., date covered SNF level of care ended) = include the date active care ended; this should match the statement covers through date on the claim. iv) Covered Days and Charges = Submit all covered days and charges as if the beneficiary had days available up until the date active care ended. v) Value Code 09 (First year coinsurance amount) 1.00 (If applicable, the FISS will assign the correct coinsurance amount based off the CWF response). vi) Patient Status Code = 30 (still patient). c) Benefits exhaust claim with a patient discharge. i) Bill Type = 211 or 214 for SNF and 181 or 184 for SB (NOTE: Bill types 210 or 180 should not be used for benefits exhaust claims submission). ii) Covered Days and Charges = Submit all covered days and charges as if beneficiary had days available up until the date active care ended. iii) Value Code 09 (First year coinsurance amount) 1.00 (If applicable, the FISS will assign the correct coinsurance amount based off the CWF response). iv) Patient Status Code = Use appropriate code other than patient status code 30 (still patient). NOTE: Billing all covered days and charges allow the Common Working File (CWF) to assign the correct benefits exhaust denial to the claim and appropriately post the claim to the patient’s benefit period. Benefits exhaust bills must be submitted monthly. 2) SNF providers shall submit no-payment claims for beneficiaries that previously dropped to non-skilled care and continue to reside in the Medicare-certified area of the facility using the following options. a) Patient previously dropped to non-skilled care. Provider needs Medicare denial notice for other insurers. i) Bill Type = 210 (SNF no-payment bill type) or 180 (SB no-payment bill type) ii) Statement Covers From and Through Dates = days provider is billing, which may be submitted as frequently as monthly, in order to receive a denial for other insurer purposes. No-payment billing shall start the day following the date active care ended. iii) Days and Charges = Non-covered days and charges beginning with the day after active care ended. iv) Condition Code 21 (billing for denial). v) Patient Status Code = Use appropriate code. b) Patient previously dropped to non-skilled care. In these cases, the provider must only submit the final discharge bill that may span multiple months but must be as often as necessary to meet timely filing guidelines. i) Bill Type = 210 (SNF no-payment bill type) or 180 (SB no-payment bill type) ii) Statement Covers From and Through Dates = days billed by the provider, which may span multiple months, in order to show final discharge of the patient. No-payment billing shall start the day following the date active care ended. iii) Days and Charges = Non-covered days and charges beginning with the day after active care ended. iv) Condition Code 21 (billing for denial). v) Patient Status Code = Use appropriate code other than patient status code 30 (still patient). NOTE: No pay bills may span both provider and Medicare fiscal year end dates. Refer to Chapter 25 for further information about billing.