CMS Updates Guidance for Medicare Part A SNF PPS PDPM Claims

PDPM; Medicare; Reimbursement

The Centers for Medicare and Medicaid Services (CMS) posted a change request transmittal CR11992 that updates the skilled nursing facility (SNF) Patient-Driven Payment Model (PDPM) claims processing instructions for claims that contain both covered and noncovered days. The effective date is April 1, 2021 and the implementation date is April 5, 2021. However, the application of the claims processing edit is retroactive to October 1, 2019 because this is a systems update and not a policy change. Provider billing staff should review the accompanying MLN Matters article MM11992 to become familiar with the new guidance.

The Medicare Part A SNF PPS PDPM payment model was implemented on October 1, 2019 and included a new “interrupted stay” policy. This policy considers a readmission or a resumption of a skilled level of care in a SNF during the first three days after discontinuing skilled care to be treated as the same stay for payment purposes. This policy has created some claims processing problems related to the PPS payment rates and consolidated billing policies upon resuming skilled care during the 3-day interrupted stay window. The following revision to SNF provider coding guidance in Chapter 6 of the Medicare Claims Processing Manual and associated Medicare claims processing systems updates will permit these claims to be processed properly.      

SNFs billing on Type of Bill (TOB) 21X and hospital swing bed providers billing on TOB 18X (subject to SNF PPS) will be subject to these requirements. The CR modifies processing and the Medicare Claims Processing Manual, Chapter 6, to adhere to current policy. 

The revised text in both Sections 40.3.2 and 40.6 of Chapter 6 of the Manual reads: 

“For claims that contain both covered days and noncovered days, and those noncovered days are the responsibility of the beneficiary (e.g., days submitted for noncovered level of care), the provider should append span code 76 to indicate the days the beneficiary is liable.” 

This change modifies existing editing to process and pay claims correctly accounting for SNF interrupted stays that are reported at the end of a month effective October 1, 2019.

A SNF interrupted stay is identified as follows: 
  • TOB = 21X or 18X (excluding CAH) AND 
  • Occurrence Span Code (OSC) 74 equal to 3 days or less AND 
  • Date of Service (DOS) 10/1/2019 or later