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Region B

Issue Title

Skilled Nursing Facility (SNF) Unrelated to Terminal Condition




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.



Provider Type


Date of Service

Dates of Service 10/1/2007--Open

42 CFR § 409.30 Basic requirements
42 CFR § 409.31 Level of care requirement
42 CFR § 409.32 Criteria for skilled services and the need for skilled services
42 CFR § 418.402 Individual Liability for Services That Are Not Considered Hospice Care (revised as of October 1, 2005)
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)
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)
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)
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)
Office of Inspector General (OIG) Report OEI-02-10-00070 Medicare Hospices That Focus On nursing Facility Residents (July 2011)

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Created at 6/5/2013 8:27 AM by Aaron Gough
Last modified at 9/21/2016 2:43 PM by Aaron Gough