SNF Spell of Illness Quick Reference Chart

40.8.1 – SNF Spell of Illness Quick Reference Chart (Rev.4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19) Level of Care Patient's Medicare SNF Part A Benefits Are Exhausted Patient Is In Medicare Certified Area of the Facility * If in non- Medicare Area, the Facility Meets the Definition of a SNF ** Is the Inpatient Spell of Illness Continued? Billing Action Medicare Skilled YES YES N/A YES Submit Monthly Covered Claim. NO YES N/A YES Submit Monthly Covered Claim. YES NO YES YES Submit Monthly Covered Claim. NO NO YES YES Patient should be returned to certified area for Medicare to be billed. Submit Monthly Covered Claim. NO NO NO NO Facility should determine whether it would be appropriate to send patient back to a certified area for Medicare coverage. Not Medicare Skilled YES NO NO NO Do not submit claim if pt came in non-skilled. Otherwise, submit no-pay claim w/ discharge status code when patient leaves the certified area. YES YES N/A NO Do not submit claim if pt came in non-skilled. Otherwise, submit no-pay claim w/ discharge status code when patient leaves the certified area. NO YES N/A NO Do not submit claim if pt came in non-skilled. Otherwise, submit no-pay claim w/ discharge status code when patient leaves the certified area. NO NO YES NO Do not submit claim if pt came in non-skilled. Otherwise, submit no-pay claim w/ discharge status code when patient leaves the certified area. YES NO YES NO Do not submit claim if pt came in non-skilled. Otherwise, submit no-pay claim w/ discharge status code when patient leaves the certified area. * Whether the facility considers a patient's bed in the certified area to be a Medicare bed or not has no effect on whether the spell of illness is continued and has no effect on the SNF's action. ** In some states, licensing laws for all nursing homes have incorporated requirements of the basic SNF definition (Social Security Act §1819(a)(1)). When this is the case, any nursing home in such a state would be considered to meet this definition (see CMS Internet-Only Manual, Pub. 100-7, Chapter 2, §2164 at www.cms.hhs.gov/manuals/ on the CMS website).