For the past several years, the Centers for Medicare and Medicaid Services (CMS) has attempted to address various system claim edits impacting Medicare Part A Hospital Inpatient and Skilled Nursing Facility Patient Driven Payment Model (SNF PDPM) in specific situations where the SNF prospective payment system PDPM interrupted stay policy occurs, and the patient is hospitalized for less than three days before returning to the SNF.
A recent CMS
MLN Matters article MM 13240 provides information about new edit updates for claims with dates of service on or after October 1, 2019, when the following occurs:
- An incoming SNF (21X or swing bed 18X) claim, excluding swing bed critical access hospital (CAH) providers, has an occurrence span code (OSC) 74 and there’s a covered or non-covered inpatient claim (11X) during the interrupted stay of the incoming SNF claim.
- An incoming inpatient claim (11X) and there’s a covered or non-covered SNF (21X or swing bed18X) claim, excluding Swing Bed CAH providers, with an OSC 74 and incoming Inpatient claim (11X) is during the interrupted stay of the SNF claim.
When one of the above conditions is present, your Medicare Administrative Contractor (MAC) will process a hospital inpatient no-pay claim (TOB 110) and:
- Pay the overlapping SNF PPS inpatient claim (TOB 21X), when OSC 74 is present indicating there’s an interrupted stay
- Pay the overlapping hospital ancillary claim (TOB 12X) and also the overlapping SNF PPS inpatient claim (TOB 21X), when OSC 74 is present indicating there’s an interrupted stay
SNF billers should review this update with an effective date retroactive to October 1, 2019, and an implementation date of January 4, 2024.