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Skilled Nursing Facility Prospective Payment System (SNF/PPS) Billing Tips


TRICARE adopted the Medicare Skilled Nursing Facility Prospective Payment System (SNF/PPS) payment methods and rates. This includes the Minimum Data Set (MDS) assessments, Resource Utilization Group (RUG) III classifications and Medicare weights and per diem rates that complete the Health Insurance Perspective Payment System (HIPPS). The billing codes are for claims with date of admission on or after August 1, 2003. Check out the Centers for Medicare and Medicaid Services (CMS) 2009 rates effective October 1, 2008.

                                                                           

SNF/PPS Billing Tips                                                           

  • The bill types that are valid for a Skilled Nursing Facility (SNF) provider are 211, 212, 213, and 214. Bill type 211 is for a complete bill and the patient status in block 17 of the UB-04 indicates the  patient has been discharged. Bill type 212 is for the initial claim only and the patient status in block 17 of the UB-04 must indicate the patient has not been discharged. Bill type 213 is an interim bill and the patient status in block 17 of the UB-04 must indicate the patient has not been discharged. Bill type 214 is the final bill and the patient status in block 17 of the UB-04 must indicate the patient has been discharged.

                                                   

  • SNF/PPS assessment indicators in block 44 and assessment dates in block 45 are calculated by the admit date noted in block block 12 UB-04 claim form and is always the first day of the inpatient stay. Please note that if the patient is discharged from the facility and readmitted later than the assessment dates and indicators will start over with an initial assessment. For example: 01,11, and 05. The next assessment would then be the 14-day assessment and so on until discharge.

                                                    

  • All SNF/PPS claims must have a value of "70" in block block 35/36 of the UB-04 claim form with an occurrence span date, unless there is no qualifying stay. A qualifying stay is a 3-day inpatient hospital stay within 30 days of admission to the SNF. If there is no qualifying stay, the claim will be denied. (If the patient was admitted after the 30 days, an appropriate condition code can be filed in block 18-28 on the UB-04. The condition codes are 55-59 and the most commonly used is 58.)

           

  • Please submit claims with valid HIPPS codes or the default HIPPS code of AAA00 in block 44.

    (If the default code of AAA00 is submitted we must also have Medical Records to process the claim.)

                                                  

  • All SNF/PPS claims must be billed with the 0022 revenue code.                            

  • If billing for Rehab Rug Codes (example - RHB, RMA,RVC, RMX) physical, speech, or occupational therapy codes must be submitted on the claim. The appropriate number of disciplines should also be submitted with each specific

    therapy Rug Code.

                            
  • SNF/PPS claims must be sequential. Please submit all SNF/PPS claims in order, using the dates of service on the claim.

                                                   

  • The TRICARE Systems Manual 7950. 1-M, August 1, 2002, Chapter 2, Section 1.1, paragraph 7.0, page 12 states:

                              

                         In certain cases, providers can submit interim bills for institutional claims.

                         All TRICARE Encounter Data (TED) records for interim (interim or final)

                         institutional bills must be submitted as an adjustment using the same

                         Internal Control Number (ICN) as the initial submission.

In accordance with the above noted policy, PGBA can no longer process interim claims separately. PGBA is  required to adjust all interim and final bills back to the original Internal Claim Number (ICN) for payment. For example: 1 of 3 claims are submitted ICN 123456789 is the initial claim (type 212), so the first bill type for 213 will be ICN 1234567890001 and the final bill type 214 will be 1234567890002.

  • The DUTs on all the room and board lines must total the time span of the dates of service. Please note that all Leave of Absence (LOA) days must be indicated with revenue code 180 and the appropriate DUTs.

                                                                      

  • All SNF/PPS claims must have a RUG code, a valid assessment indicator and a valid assessment date performed within the grace period. A default RUG code of AAA00 may be used with the appropriate assessment date.

         

NOTE: We use the same codes as Medicare until the 100th day of inpatient care.

 

These are the most commonly used Medicare required assessment indicators for the first 100 days of the stay:

                               

01 = 5 day assessment                  07 = 14 day assessment            02 = 30 day assessment

                                                                         

03 = 60 day assessment                04 = 90 day assessment

                                               

There are other valid assessment indicators that can be used. For example: Other Medicare Required Assessment (OMRA), Significant Correction of a Prior Assessment (SCPA) and Significant Change in Status Assessment (SCSA).

                                                                     

Since TRICARE coverage can continue after the 100th day of the stay, the following assessment indicators should be filed on the claim:

                                                             

120th day = 8A     150th day = 8B     180th day = 8C     210th day = 8D

                                                                     

240th day = 8E     270th day = 8F     300th day = 8G     330th day = 8H

                                                                    

360th day = 8I       Post 360th day of care within 30 day intervals = 8X

 


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