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Region

Region B

Issue Title

Skilled Nursing Facility (SNF) Unrelated to Terminal Condition

Number

 

Description

A hospice beneficiary certified as having a terminal illness with a life expectancy of 6 months or less waives all rights to Medicare payment for services related to the terminal condition. Services unrelated to the terminal condition may still be payable and are designated by the presence of condition code 07. SNF Part A claims with a condition code 07 will be reviewed to validate that the services did not relate to the patient’s terminal condition and met SNF coverage criteria.

States

MN, WI, MI, IL, IN, OH, KY

Provider Type

SNF

Date of Service

Dates of Service 10/1/2007--Open

References

http://edocket.access.gpo.gov/cfr_2002/octqtr/42cfr409.30.htm
42 CFR § 409.30 Basic requirements

http://edocket.access.gpo.gov/cfr_2007/octqtr/42cfr409.31.htm
42 CFR § 409.31 Level of care requirement 

http://edocket.access.gpo.gov/cfr_2005/octqtr/42cfr409.32.htm
42 CFR § 409.32 Criteria for skilled services and the need for skilled services

http://edocket.access.gpo.gov/cfr_2005/octqtr/42cfr418.402.htm
42 CFR § 418.402 Individual Liability for Services That Are Not Considered Hospice Care (revised as of October 1, 2005)

https://www.cms.gov/manuals/Downloads/bp102c09.pdf
CMS IOM 100-2 (Medicare Benefit Policy Manual), Chapter 9, Section 10 – Requirements – General (Rev.141, Issued: 03-02-11, Effective: 01-01-11: Implementation: 03-23-11)

https://www.cms.gov/manuals/downloads/clm104c06.pdf
CMS IOM 100-4 (Medicare Claims Processing Manual), Chapter 6, Section 20.2.2 – Hospice Care for a Beneficiary’s Terminal Illness (Rev.229, Issued 07-20-04 Effective/Implementation 08-19-04) 

https://www.cms.gov/manuals/downloads/clm104c11.pdf
CMS IOM 100-4 (Medicare Claims Processing Manual), Chapter 11, Section 50 – Billing and Payment for Services Unrelated to Terminal Illness (Rev.2258, Issued: 07-29-11, Effective: 01-01-12, Implementation: 01-03-12)

https://www.cms.gov/manuals/downloads/pim83c06.pdf
CMS 100-8 (Program Integrity Manual), Chapter 6, Section 6.1.3B – Make a Coverage Determination (Rev.196, Issued: 03-30-07, Effective: 01-01-06, Implementation: 04-30-07)

http://oig.hhs.gov/oei/reports/oei-02-10-00070.pdf
Office of Inspector General (OIG) Report OEI-02-10-00070 Medicare Hospices That Focus On nursing Facility Residents (July 2011)

Date Posted

 

Date Revised

 

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Created at 6/5/2013 8:27 AM by Aaron Gough
Last modified at 6/5/2013 10:36 AM by Aaron Gough