Skilled Nursing Facilities

Skilled nursing facility (SNF) and swing bed (SB) providers must submit either a qualifying hospital stay or an appropriate condition code for bypassing the qualifying stay, if applicable, on all claims including initial and subsequent claims that are submitted as covered. This is applicable for submitted bill types 21x (SNF inpatient) and 18x (SB inpatient). This also includes all covered claims (i.e., claims submitted for benefits exhaust denials). Covered claims submitted on 21x and 18x bill types that do not contain a qualifying hospital stay (using occurrence span code 70 with the qualifying hospital stay dates) or an appropriate condition code indicating why a qualifying hospital stay is not applicable will be denied.

Reference:

• MLN Matters article for Change Request 6233 (PDF)

Last Reviewed: 12/19/2024

If a patient elects hospice, a timely-filed hospice notice of elections (NOEs) shall be filed within five (5) calendar days after the hospice admission date. A timely-filed NOE is one that is submitted to and accepted by the Medicare contractor within five (5) calendar days after the hospice election. The practical meaning of “submitted to and accepted by the Medicare contractor” is that the NOE was not returned to the provider for correction.

Example: The date of hospice election is October 1. A timely-filed NOE would be submitted and accepted by the Medicare contractor on or before October 6.

In instances where the NOE is not timely-filed, Medicare shall not cover and pay for the days of hospice care from the hospice admission date to the date the NOE is submitted to, and accepted by, the Medicare contractor. The provider shall be liable for these days, and the provider shall not bill the beneficiary for them.

Example: The date of hospice election is October 1. The NOE was not submitted and accepted by the Medicare contractor until October 10. Provider-liable days would be October 1 through October 9.

An individual or patient representative may revoke the election of hospice care at any time in writing; however, a hospice cannot “revoke” a patient’s election. To revoke the election of hospice care, the individual must file a document with the hospice provider that includes:

• A signed statement that the individual revokes the election for Medicare coverage of hospice care for the remainder of that election period
• The effective date of that revocation
• A designated effective date earlier than the date that the revocation is made

The individual forfeits hospice coverage for any remaining days in that election period. Please note that an oral revocation of benefits is not acceptable.

Upon revoking the election of Medicare coverage of hospice care for a particular election period, the individual is no longer covered under the Medicare hospice benefit, and resumes Medicare coverage of the benefits waived when hospice care was elected. An individual may, at any time, elect to receive hospice coverage for any other hospice election periods that he or she is eligible to receive.

CMS billing guidance is:

• When a beneficiary elects hospice during an inpatient stay:
  • Bill traditional Medicare for period before hospice election
  • Patient status code is 51 (discharge to hospice medical facility)
  • Discharge date is the effective date of hospice election
  • Bill hospice for period of care after hospice election
• When a patient revokes hospice during an inpatient stay:
  • Bill hospice for period up to hospice revocation
  • Bill traditional Medicare for period after hospice revocation
  • Admission date is same as the hospice revocation date
  • Statement 'from' date is the same as the hospice revocation date

Reference:

• CMS IOM Publication 100-02, Medicare Benefit Policy Manual Chapter 9, Section 20 (PDF)

Last Reviewed: 12/19/2024

The skilled nursing facility (SNF) consolidated billing list is located on the Centers for Medicare & Medicaid Services (CMS) website. You can access the individually excluded codes by completing the following steps:

1. Go to the CMS SNF Consolidated Billing website  
2. Select the update for the year of the claim you are researching codes for (e.g., if the dates of service on your claim are for 020110 through 022810, you would select the 2010 A/B MAC update
3. Scroll to the bottom of the page and select the appropriate year for the SNF Consolidated Billing Annual Update needed for your claim

Last Reviewed: 12/19/2024