|
|
Region B Issues
Page Content
Name |
Skilled Nursing Facility (SNF) Psychiatric Condition
|
Description |
Patients with only a psychiatric condition who are transferred from a psychiatric hospital to a participating SNF are likely to receive only non-covered care. Also, patients whose primary condition/needs are psychiatric in nature often require considerably more specialized, sophisticated nursing techniques and physician attention than is available in most participating SNFs. (SNFs primarily engaged in treating psychiatric disorders are precluded by law from participating in Medicare.)
|
Type of Review |
Complex
|
States |
MN, WI, MI, IL, IN, OH, KY |
Provider type |
SNF |
Date of service |
Dates of Service 10/1/2007--Open
|
References |
42 CFR § 409.30 Basic requirements - link
42 CFR § 409.31 Level of care requirement - link
CGS LCD L31952 - Effective 04/30/11 for J15 MAC states (OH, KY) - link
NGS Local Medical Policy Article A50641 - Effective 02/01/2011 for FI states (WI, MI, IL, IN) and effective 02/01/11 through 03/31/11 for FI states (OH, KY) - link
NGS LCD L26861 - Effective 07/01/2008 through 01/31/2011 for FI states (WI, MI, IL, IN, KY, OH) - link
CMS IOM 100-2, Chapter 8, Section 20.1 and Section 30.2.3.2 - link |
Name |
Skilled Nursing Facility (SNF) Unrelated to Terminal Condition
|
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.
|
Type of Review |
Complex
|
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) |
Name |
SNF Consolidated Billing |
Description |
Services are being billed separately that should be included in the Skilled Nursing Facility Consolidated billing. Consolidated Billing is when services provided during the resident's stay in a skilled nursing facility (SNF) are bundled into one package and billed by the Skilled Nursing Facility. Under the Consolidated Billing requirement, a Skilled Nursing Facility itself must submit all Medicare claims for the services that its residents receive (except for specifically excluded services). |
Type of Review |
Automated Overpayment
|
States |
MN, WI, MI, IL, IN, OH, KY |
Provider type |
SNF |
Date of service |
Dates of Service 7/1/2008--Open
|
References |
CMS Pub 100-04; Chapter 6 § 10, 20, 80 and 110.2.2; and,CMS Pub 100-04; Chapter 20 § 211
Pub 100-04 Medicare Claims Processing Centers for Medicare & Medicaid Services (CMS)
CMS Manual System Department of Health & Human Services (DHHS) Pub 100-04 Medicare Claims Processing Centers for Medicare & Medicaid Services (CMS) Transmittal 1750 Date: June 5, 2009
|
Name |
Untimed Codes |
Description |
CPT codes (excluding modifiers KX, and 59) where the procedure is not defined by a specific timeframe (untimed codes), the provider should enter a one (1) in the units billed column per date of service. |
Type of Review |
|
States |
IL, IN, KY, MI, MN, OH, WI |
Provider type |
Physician / Outpatient Hospital |
Date of service |
October 1, 2007-Present
|
References |
CMS Pub 100-04, Transmittal 1019, dated 8.3.06, pages 7-11.
CMS Pub 100-04, Ch. 5, § 20.2.
|
|
|
|