Last Modified: 9/26/2024
Location: FL, USVI, PR
Business: Part A
CMS defines an ‘interrupted’ SNF stay as one in which a patient is discharged from Part A covered SNF care and subsequently readmitted to Part A covered SNF:
• This definition applies to patients who drop to a non-skilled level of care, but remain in the facility (lower level of care change (LLCC) claims)
If a patient is discharged from a SNF and readmitted to the same SNF less than three consecutive calendar days after discharge or LLCC date, then the subsequent stay is considered a continuation of the previous stay:
• Assessment schedule continues from the point just prior to discharge. No new assessment is required.
• The variable per diem will not reset to day one. (The 300% will not reset)
• Variable per diem schedule continues from the point just prior to discharge.
• This is considered an interrupted stay and bill accordingly using occurrence span code (OSC) 74.
If patient is discharged from a SNF and readmitted to the same SNF or a different SNF more than three consecutive calendar days after discharge or LLCC date, then the subsequent stay is considered a new stay:
• SNF discharges the beneficiary and submits a readmission claim.
• Because the first stay is considered to have ended if the interruption window of three days has passed, the resumption of skilled care would be considered an entirely new stay.
• A new five-day assessment is required.
• Variable per diem schedule reset to day one. (The 300% will reset)
If patient is at a LLCC for more than three consecutive days but less than 30 days and is brought back up to a covered Part A stay:
• This is not considered an interrupted stay.
• The provider should bill the LLOC portion of the claim with the OSC 76.
• The provider must bill value code (VC) 31 with the amount the beneficiary is responsible for.
• The provider must complete a new assessment within eight days of the through date of the OSC 76.
• The variable per diem schedule will reset to day one. (The 300% will reset)
If patient is at a LLCC for more than 30 consecutive days and is brought back up to a covered Part A stay:
• If the LLCC is greater than 30 days, the beneficiary is required to have a new qualifying hospital stay (QHS) in order for Medicare to cover the Part A stay.
• If the beneficiary did not have a new QHS:
• The claim should be billed as covered with the admit date as the date when brought back up to skilled care.
• The claim should not include the OSC 70.
• The initial claim where the patient drops to a LLCC:
• Type of bill (TOB) 21x (not a no-pay).
• Apply the occurrence code (OC) 22 (the last covered day).
• Apply OSC 76 for the dates of LLCC.
• If the LLCC period is for an entire month or multiple months:
• TOB 210.
• Condition code 21 with remarks indicating lower level of care.
• OSC 76 dates equal the from and through dates of the claim.
• Apply VC 31 with the amount the beneficiary is responsible for.
• If the patient drops to LLOC and is brought back up within the same month:
• TOB 21x (not a no pay).
• Bill one claim for the entire month.
• Do not include the occurrence code 22.
• Apply OSC 76 for the dates of LLOC.
• Apply VC 31 with the amount the beneficiary is responsible for.
• TOB 21X.
• Value code (VC) 81 with the number of interrupted days.
• Revenue code 018X with the number of units and ‘0’ charges.
• If the stay is less than three days, report OSC 74 with the from and through dates of the non-covered days (dates of the interruption).
• If the stay is over three days, report OSC 76 with the from and through dates of the non-covered days and VC 31 with the amount the beneficiary is responsible for.
Example 1:
Patient A is admitted to SNF on November 7, admitted to hospital on November 20, and returns to the same SNF on November 25.
• New stay.
• Assessment schedule: Reset; stay begins with new 5-day assessment.
• Variable per diem: Reset; stay begins on day one of variable per diem schedule.
Example 2:
Patient B is admitted to SNF on November 7, admitted to hospital on November 20, and admitted to a different SNF on November 22.
• New stay.
• Assessment schedule: Reset; stay begins with new 5-day assessment.
• Variable per diem: Reset; stay begins on day one of variable per diem schedule (300% restarts).
Example 3:
Patient C is admitted to SNF on November 7, admitted to hospital on November 20, and returns to the same SNF on November 22.
• Continuation of previous stay.
• Assessment schedule: No prospective payment system (PPS) assessments required; IPA optional.
• Variable per diem: Continues from Day 14.
Example 4:
Patient D has an LLCC on December 10, and then picked back up as skilled on December 20.
• This is more than 3 days.
• SNF reports OSC 76 for the non-covered days and VC 31 with the amount the beneficiary is responsible for.
• Uses the original qualifying hospital stay (if within 30 days).
• Assessment schedule: A new assessment is required and must be dated the day after the through date of the OSC 76 date.
• Variable per diem: Reset; stay begins on day 1 of variable per diem schedule (300% restarts).
Note: 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.
Example 5:
Patient E has a LLCC on 12/10 and then picked back up as skilled on 12/12.
• This is less than 3 days.
• SNF reports occurrence span code 74 for the non-covered day.
• Uses the original qualifying hospital stay.
• Assessment schedule: this is a continuation so no new assessment.
• Variable per diem: continuation, 300% does not restart.
1. Is CMS’ intention that if a non-skilled level of care lasts more than 3 days, and then beneficiary is brought back to a skilled level of care and never leaves the facility, that the variable per-diem is restarted at day one?
• Yes.
2. If yes to question 1, how is the claim to be submitted to allow the variable per-diem to start at day one as the admission date remains the same?
• Because the first stay is considered to have ended if the interruption window of 3 days has passed, the resumption of skilled care would be considered an entirely new stay. The date of admission of the new Part A SNF stay would be the day that covered skilled care resumed.
3. Per the SNF PDPM FAQs, non-skilled care should be treated as a discharge, is this to be interpreted as a required discharge if the non-skilled care lasts more than three days?
• Yes. If non-skilled care lasts more than 3 days, the interruption window has expired, and the initial SNF Part A stay is considered to have ended.
4. How do I bill a claim if there is a leave of absence or LLCC change over the month end, for example the provider fiscal year?
• Claims with a leave of absence or LLCC over the month end (including the fiscal year) are billed as usual.
• For example, if the patient was admitted to the SNF on September 30 and discharged to home on October 15, but was admitted to an acute care hospital on September 30 and returned to the SNF on October 1, bill as follows:
First claim:
Type of bill (TOB) 212
Date of service (DOS) 9/1 to 9/30
OSC 74 9/30
Patient status code 30
Discharge claim:
TOB 214
DOS 10/1-10/15
Patient status code 01
References:
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