When it comes to reimbursement for Long Term Care there are a lot of ongoing changes and regulations. We have complied some of the most Frequently Asked Questions in this category in hopes to deliver information and education on this topic.
Q. Once a patient ends their SNF Part A benefit days, does that count towards the 60-day break? Can an SNF submit a claim for Part B therapies once a patient exhausts their SNF benefit days?
A. One of the major determinants of a patient’s eligibility for a 60-day break with an aim to benefit from a fresh benefit period is that of the level of care. If a patient is still undergoing care which previously would have fulfilled benefits criteria, a benefits exhaust claim must be made. For benefit exhaust claims, the SNF must submit a monthly benefits exhaust bill for patients who are undergoing specialized care. The process is unchanged irrespective of who pays the benefits exhaust bill (i.e. Medicaid, insurance or private payment). Benefits exhaust bills must be claimed on a monthly basis to extend the patient’s applicable benefit period within the common working file (CWF).
The patient’s benefit period terminates 60 days after they have been discharged from an inpatient healthcare facility and has not been the recipient of specialized care in an SNF during this 60-day period. If the patient is still admitted in an inpatient healthcare facility and is the recipient of specialized care after their Part A benefits have been exhausted, then this would not go towards the 60-day break.
Patients who continue to be recipients of specialized care (e.g. Part B therapy) once SNF Part A benefits have been exhausted, the SNF can initiate an inpatient ancillary claim (22X) once the benefits exhaust claim is processed.
Reference
CMS Publication 100-04, Claims Processing Manual, Chapter 6, Sections 40.7 & 40.8

Q. If a resident remains at a skilled level of care after benefits exhaust, do we continue to submit a benefit exhaust claim until the patient drops to a lower level of care? Do we submit ‘no-pay’ claims once the patient begins a lower level of care?
A. SNFs must submit a bill regardless of whether the benefits in question are payable by Medicare. The CMS documents all inpatient services undertaken by the patient. A SNF must submit benefit exhaust bills on a monthly basis for patients who are recipients of specialized care as well as when there is an escalation or de-escalation in the level of care. These monthly benefit exhaust bill claims are necessary for extending the patient’s benefit period within the CWF. If and when there is an escalation or de-escalation of care, the SNF should submit a benefits exhaust bill in the next billing cycle that clearly states that active care has ceased. Part B 22X bills can be submitted once this has been performed.
Reference
CMS Publication 100-04, Claims Processing Manual, Chapter 6, Section 40.8

Q. Where can I find information on leave of absence days?
A. A leave of absence is defined as the period in which the patient is missing, but has not been discharged as per the hospital’s workflow processes. Patients who are deliberately referred and transferred to other healthcare institutions (e.g. tertiary hospital or skilled nursing facility) are excluded from this period.
Reference
CMS Publication 100-04, Claims Processing Manual, Chapter 6, Section
40.3.5.2

Q. Patients have Medicare and other insurers as primary from day one of admission. If we have been doing the minimum data set (MDS) from day one and the beneficiary converts to traditional Medicare, do we start over with the 5-day MDS? Or can we pick up where we left off with the MDS schedule started on day one?
A. In order for Medicare to undertake payment for specialized services provided to a patient under a Part A SNF stay, the SNF must complete an MDS. This is strongly recommended especially when Medicare is secondary. The Medicare assessments must begin on the 1st day of the residents Medicare coverage.
MDS 3.0 Resident Assessment Instrument (RAI) User's Manual
Q. When would an MDS assessment schedule start again?
A. Once the patient has been discharged (and not leave of absence) from the SNF for more than 24 hours, or has been discharged and re-admitted, a new MDS must begin.
Q. What qualifies as a 3-day qualifying stay for SNF inpatient stay purposes?
A. The patient must have been admitted in a Medicare-approved inpatient hospital for at least 3 consecutive days. This qualifying criterion does not include the day of discharge. In other words, a patient admitted to a hospital on 10/11/2019 and discharged to an SNF on 10/14/2019 would meet the criterion for the 3-day qualifying stay. This is because the patient was admitted as an inpatient on 10/11, 10/12 and 10/13. 10/14 was not considered as that was the day of discharge. Outpatient services such as observation do not qualify for this criterion. Additionally, the SNF services provided must have been indicated for conditions which warranted treatment in the hospital, or a condition which arose within the SNF whilst being treated for a primary condition for which hospitalization was warranted.
A 3-day admission within a psychiatric facility would meet the criterion for a prior hospital stay, but patients who exclusively have a psychiatric condition and are subsequently transferred to an SNF are likely to be recipients of non-covered care. Non-covered care in this context refers to a level of care that is less advanced and comprehensive compared to the SNF level of care that is covered.
Reference
CMS Publication 100-02, Benefit Policy Manual, Chapter 8, Section 20

