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Region D Issues
Page Content
Name |
Excessive Units SNF 30 day assessment - J1
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Description |
The “30 day” Medicare MDS
Assessment Type authorizes coverage and payment for a maximum of 30 days.
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Type of Review |
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States |
CA, HI, and NV |
Provider type |
SNF |
Date of service |
Claims having a claim paid date within three years of the ADR |
References |
Federal Register 63 FR
26252 Medicare Skilled Nursing Facility Manual Change Request 2362
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Name |
Excessive Units SNF 60 day assessment - J1
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Description |
The “60 day” Medicare MDS Assessment Type authorizes coverage and payment for a maximum of 30 days.
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Type of Review |
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States |
CA, HI, and NV |
Provider type |
SNF |
Date of service |
Claims having a claim paid date within three years of the ADR |
References |
Federal Register 63 FR 26252 Medicare Skilled Nursing Facility Manual Change Request 2362
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Name |
Skilled Nursing Facility Medical Necessity
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Description |
Skilled Nursing Facility (SNF) stays will be reviewed for documentation of covered SNF services that are medically reasonable and necessary |
Type of Review |
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States |
AK, AZ, CA, HI, IA, ID, KS, MO, MT, ND, NV, OR,SD, UT, WA, WY, Guam, American Samoa and Northern Marianas |
Provider type |
SNF |
Date of service |
Claims having a claim paid date within three years of the ADR |
References |
CMS Publication 100-02 Chapter 8, Section 30 - 40 MDS 3.0 RAI Manual: CMS Publication 100-08 Chapter 6 §6.1 - 6.3 Social Security Act -1862A(1)a
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Name |
SNF Consolidated Billing for Therapies During a Part B SNF Stay
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Description |
For Medicare beneficiaries in a SNF Part B stay, therapies are subject to SNF consolidated billing. Outpatient physical therapy, outpatient speech-language pathology services, and outpatient occupational therapy are billable services by the SNF even when another entity renders the services under arrangement with the SNF. |
Type of Review |
Automated Review |
States |
AK, AZ, CA, HI, IA, ID, KS, MO, MT, ND, NV, OR,SD, UT, WA, WY, Guam, American Samoa and Northern Marianas |
Provider type |
Physician |
Date of service |
Claims that have a “claim paid date” which is more than 3 years prior to the Demand Letter date |
References |
1) Medicare Claims Processing Manual: CMS Pub 100-04; Chapter 7 § 10.1, 40 and 110. 2) Overview on Skilled Nursing Facility (SNF) Consolidated Billing (CB) 3) Carrier File Explanation SNF Consolidated Billing
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Name |
Visits to Patients in Swing Beds
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Description |
If the inpatient care being billed by the hospital with swing bed approval is for nursing facility care, then the nursing facility codes apply. |
Type of Review |
Automated Review |
States |
AK, AZ, CA, HI, IA, ID, KS, MO, MT, ND, NV, OR,SD, UT, WA, WY, Guam, American Samoa and Northern Marianas |
Provider type |
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Date of service |
Claims that have a “claim paid date” which is more than 3 years prior to the Demand Letter date |
References |
Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 30.6.9.
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Name |
Untimed Codes |
Description |
Description Untimed Codes – 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 |
Automated Review |
States |
AK, AZ, CA, HI, IA, ID, KS, MO, MT, ND, NV, OR,SD, UT, WA, WY, Guam, American Samoa and Northern Marianas |
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.
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Name |
SNF Consolidated Billing Payment |
Description |
SNF Consolidated Billing Payment for the majority of Skilled Nursing Facility (SNF) services provided to beneficiaries in a Medicare covered Part A SNF stay are included in a bundled prospective payment made through the fiscal intermediary (FI)/A/B Medicare Administrative Contractor (MAC) to the SNF. These bundled services are to be billed by the SNF to the FI/A/B MAC in a consolidated bill.
Physician's professional services are excluded from this consolidated billing requirement; however, for physician services delivered to SNF inpatients, the technical component (representing the performance of the diagnostic procedure itself) is bundled into the Part A PPS payment and are not paid separately.
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Type of Review |
Automated Review |
States |
AK, AZ, CA, HI, IA, ID, KS, MO, MT, ND, NV, OR,SD, UT, WA, WY, Guam, American Samoa and Northern Marianas |
Provider type |
DME Part B and Part A |
Date of service |
Claims paid on or After October 1, 2007 |
References |
CMS Pub 100-04; Chapter 6 § 10, 20, 80 and 110.2.2; and CMS Pub 100-04; Chapter 20 § 211
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