Skilled Nursing Facility (SNF)
Q. Is there a flow chart or presentation demonstrating financial payor for services (Medicare or Facility)?
A. This reference chart provides Medicare claims processing information related to Skilled Nursing Facility (SNF) spells of illness. (January 2008) (ICN# 006846) Formats available: Downloadable only: http://www.cms.hhs.gov/MLNProducts/downloads/SNFSpellIllnesschrt.pdf 
This fact sheet provides the elements of the Skilled Nursing Facility Prospective Payment System. (October 2007) (ICN# 006821): http://www.cms.hhs.gov/MLNProducts/downloads/snfprospaymtfctsht.pdf
This Web-based training course contains information about Skilled Nursing Facility Consolidated Billing “under arrangement” agreements between Skilled Nursing Facilities and other providers or suppliers. (October 2007): http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=1 
(Last Modified 7/1/08)
Source: www.cms.hhs.gov
Q. Who is responsible for paying pathology laboratory charges? Medicare Part B had denied this service stating that Medicare Part A is responsible. Should the provider then bill the SNF or appeal to Medicare Part B?
A. The Centers for Medicare & Medicaid Services (CMS), Internet Only Manual (IOM) - Publication 100-04, chapter 7, section 90 states,
SNFs must make arrangements under Part A and may make arrangements under Part B under which the SNF bills the intermediary and receives payment. Under this process, the SNF pays the lab for services whatever amount the SNF and the lab agree on, and the beneficiary may not be charged by the lab.
Laboratory tests performed for the SNF’s Medicare inpatients covered under Part A are included in the PPS SNF payment. (http://www.cms.hhs.gov/manuals/downloads/clm104c07.pdf )
)Chapter 16, section 40.4 – Special SNF Billing Exceptions for Laboratory Tests states,
The law permits SNFs to submit a Part B claim to the FI for laboratory tests that it makes arrangements for another entity to perform on the SNF’s behalf. (http://www.cms.hhs.gov/manuals/downloads/clm104c16.pdf )
)As a SNF provider you can save the following link as a favorite and monitor the CMS Web site for changes to the SNF policies, etc. http://www.cms.hhs.gov/center/snf.asp
Finally, the laboratory should submit a bill to the SNF and they should reimburse the laboratory. You do not have to appeal to Medicare Part B.
(Last Modified 7/1/08)
Source: www.cms.hhs.gov
A. The CMS IOM, Publication 100-4, Chapter 16, section 40.4.1 – “Which Contractor to Bill for Laboratory Services Furnished to a Medicare Beneficiary in a SNF” explains the following:
• Inpatient Part A beneficiary
• Inpatient Part B beneficiary (benefits exhausted or no Part A entitlement)
• Outpatient Part B
It states the reference laboratory should bill the carrier under Part B.
(Last Modified 7/1/08)
Q. Does the 3-day qualifying hospital stay count for a patient who has Medicare replacement Health Maintenance Organization (HMO) and the resident returns to Medicare while in the SNF?
A. The CMS IOM, Publication 100-02, Chapter 8, Section 20, states: “In order to qualify for post-hospital extended care services, the individual must have been an inpatient of a hospital for a medically necessary stay of at least three consecutive calendar days.”
(Last Modified 7/1/08)
A. The Part B Fee Schedule Look-up tool available on this Web site allows you to perform a look up on the Part B fee schedules.
In addition, CMS provides a chart for SNFs that outlines type of service, billing information, and CMS manual references: http://www.cms.hhs.gov/SNFPPS/Downloads/3ruralchart.pdf
(Last Modified 7/1/08)
Q. Why are Medicare Secondary Payer (MSP) claims denied when submitted with occurrence code 24 and notes on page 4?
A. If there is an open primary insurer file, the claim will deny due to the common working file edits. When you place an occurrence code 24 – “Date Insurance Denied”, the date and remarks on your claim, a claim representative will review the claim per CMS’ instructions. When adding remarks, make sure you are as specific as possible and why you want Medicare to pay the claim.
(Last Modified 7/1/08)
Q: My claim was denied because the patient was in a Skilled Nursing Facility (SNF) and consolidated billing applies. What is included in consolidated billing?
A: One of the provisions of the Balanced Budget Act (BBA) of 1997 (Section 4432 (b)) requires consolidated billing for Skilled Nursing Facilities (SNFs). The consolidated billing requirement confers on the Skilled Nursing Facility (SNF) the billing responsibility for the entire package of care that residents receive during a covered Part A SNF stay and physical, occupational, and speech therapy services received during a non-covered stay.
A limited number of services are specifically excluded from consolidated billing and therefore separately payable. These exceptions, as well as additional information concerning SNF consolidated billing, can be found on the CMS Web site at www.cms.hhs.gov/SNFConsolidatedBilling/ .
.(Last Modified 10/3/07)
Source: CMS Internet Only Manual (IOM) Publication 100-04 Medicare Claims Processing Manual, Chapter 6, Section 10.1; BBA 1997, section 4432 (b); CMS Web site: www.cms.hhs.gov/SNFConsolidatedBilling/ .
.Q: What is the Skilled Nursing Facility Prospective Payment System (SNF PPS) and where can I find information on it?
A: (Revised 10/2/07) Section 4432(a) of the Balanced Budget Act (BBA) of 1997 modified how payment is made for Skilled Nursing Facility (SNF) services. Effective with cost reporting periods beginning July 1, 1998, SNFs are paid a comprehensive per diem under a prospective payment system (PPS). This SNF PPS per diem represents Medicare’s payment for all costs of furnishing covered Part A SNF services (routine, ancillary, and capital-related costs), except for costs associated with operating approved educational activities and costs of those services that are excluded from SNF Consolidated Billing (CB).
For more information on SNF PPS, visit the CMS Web site at: www.cms.hhs.gov/SNFPPS/ . After reviewing the Overview page, select the Highlights link on the left to view some of the key points concerning SNF PPS.
. After reviewing the Overview page, select the Highlights link on the left to view some of the key points concerning SNF PPS.To view the publication on the Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for Fiscal Year 2008, visit the CMS Web site at: www.cms.hhs.gov/center/snf.asp .
.(Last Modified 10/2/07)
Source: CMS Internet Only Manual (IOM) Publication 100-04 Medicare Claims Processing Manual, Chapter 6, Section 10; BBA 1997, section 4432 (b); CMS Web site: www.cms.hhs.gov/SNFPPS/ & www.cms.hhs.gov/center/snf.asp ;
CMS Medicare Learning Network (MLN) Product - Skilled Nursing Facility Prospective Payment System Fact Sheet, ICN 006821, September 2006.
& www.cms.hhs.gov/center/snf.asp ; CMS Medicare Learning Network (MLN) Product - Skilled Nursing Facility Prospective Payment System Fact Sheet, ICN 006821, September 2006.
