Type of care & services provided

• Nursing homes offer the most extensive care a person can get outside a hospital. Nursing homes offer help with custodial care — like bathing, getting dressed, and eating — as well as skilled care. Skilled nursing care is given by a registered nurse and includes medical monitoring and treatments.
• Skilled care also includes services provided by specially trained professionals, such as physical, occupational, and respiratory therapists.
• Services include Room and board, Monitoring of medication, Personal care, 24 Hour emergency care, social and recreational activities

Assisted living facility:

• The CPT manual describes assisted living facilities as those that provide room, board, and other personal assistance services, generally on a long-term basis.
• These facilities do not include a medical component.

Skilled Nursing Facility:

• Skilled nursing communitiesprovide 24/7 skilled nursing care for individuals requiring specialized medical care or daily therapy services in a skilled-care setting. Although sometimes temporary, a stay in a skilled nursing community could be likened to a long-term hospital stay.

Medicare Billing for SNF

• If Medicare pays the claim, the SNF must bill the agency within 6 months of the date Medicare processes the claim.
• If Medicare denies payment of the claim, the SNF must meet the agency’s 365-day requirement for an initial claim

Eligibility and coverage requirements for SNF:

• He or she was an inpatient of a hospital for a medically necessary stay of at least 3 consecutive days (counting the day of admission, but not counting the day of discharge or any preadmission time spent in the emergency room or in outpatient observation).
• He or she transferred to a Medicare-certified SNF within 30 days after discharge from the hospital unless both of these are true:
• His or her condition makes it medically inappropriate to begin an active course of treatment in a SNF immediately after discharge It is medically predictable at the time of the hospital discharge that he or she will require covered care within a predetermined time period and the care begins within that time frame
• He or she requires skilled nursing services or skilled rehabilitation services on a daily basis which, as a practical matter, can be provided only in a SNF on an inpatient basis.
• SNF admission must follow a minimum hospital stay of three consecutive days. The patient must have been officially admitted to the hospital, not just held under observation.

SNF Bill for a client discharged within current Month

• Readmission occurs when the beneficiary is discharged and then readmitted to the SNF, needing skilled care, within 30 days after the day of discharge.
• Such a beneficiary can then resume using any available SNF benefit days, without the need for another qualifying hospital stay.
• The same is true if the beneficiary remains in the SNF for custodial care after a covered stay and then develops a new need for skilled care within 30 consecutive days after the first day of non-coverage.

SNF Billing for date of Discharge or Date of death

• The SNF must bill for the date of discharge using the appropriate Patient Status code.
• The agency does not pay the nursing facilities for the date of discharge unless the client is admitted and dies on the same day. If the client is admitted and dies on the same day, then the nursing facility must use Patient Status 20 when billing for this claim

POS code:

Physicians must report the correct POS code in two places on the claim form

11- Office and 31- Skilled nursing facility, 32 nursing facility

Modifier:

To be paid appropriately for providing nursing home services to Medicare patients receiving hospice care, physicians must append one of the following modifiers:

• GV (when a provider performs a service related to the problem for which a patient was admitted into hospice)
• GW (when the service is not related to the hospice patient’s terminal condition)

26 Modifier:  The professional component of the services represented by these codes are not subject to skilled nursing facility (SNF) consolidated billing and will be considered for payment by the Part B MAC for Medicare beneficiaries in a SNF Part A stay. These codes must be submitted with a modifier of 26 to indicate “professional component”.