A clarification on billing for CAH swing bed services
Medicare Update for CAHs, November 14, 2012
In our last edition, we discussed a scenario about billing for CAH swing bed services that has confused some of our readers. In fact, this same issue has come up a number of times in recent articles we have done, so we thought that it would be helpful to take a look at exactly what is causing this confusion.
Here is the scenario that we presented:
Scenario: George, a Medicare patient, was in a covered swing bed stay receiving skilled nursing for complications related to a heart attack. During the stay, George began to complain of severe headaches, so the physician ordered a CT of the brain with and without contrast. After reviewing the exam, the physician determined the findings were normal and no additional treatment or skilled services were required, so the physician discharged George and he was free to go home. The CAH will bill the charges for the CT scan on an outpatient claim because the procedure is listed as one of the major categories for skilled nursing facility (SNF) consolidating billing.
False. Although the CT scan is considered a major category and is an “excluded” service under the SNF PPS consolidated billing requirements, CAHs are exempt from using the list and services provided while the patient is in a CAH’s swing bed should be included on the swing bed claim, regardless of the reason for the service, the findings, or whether additional services were required. <Social Security Act §§ 1888(e)(7), 1883(b)(3), 42 CFR 413.114, MLN Matters SE0606>
In the past, we’ve covered similar scenarios as well, and most people say that the guidance we presented conflicts with guidance they have received from their Medicare administrative contractor (MAC). The MAC may have told them that services listed as excluded under the SNF consolidated billing rules should be billed on a separate outpatient claim, type of bill (TOB) 85X. However, a CAH bills all swing bed services on the swing bed claim, TOB 18X, because the CAH is paid cost for its swing bed services. There is some confusion here because there are two types of swing beds – those paid under the skilled nursing facility prospective payment system, (SNF PPS) and for those paid cost as a CAH swing bed – and some Medicare contractors and consultants do not completely understand the difference.
Let’s take a look at the history of this confusion and some citations you can reference if your MAC is giving you conflicting guidance. The Balanced Budget Act of 1997 required swing beds to be incorporated into the SNF PPS beginning July 1, 2002.
Swing beds paid under the PPS use the minimum data set (MDS) form for data collection and facilities bill their services using a resource utilization group (RUG) and assessment indicator (AI) to identify the resource utilization and intensity of services.
The Benefits Improvement and Protection Act of 2000 made CAHs exempt from the SNF PPS beginning with cost reporting periods December 21, 2000. CAHs began to be paid at 101% of reasonable costs with reporting January 1, 2004. MLN Matters article SE0606 mentions this change but CMS was not really clear and many CAH continued to bill swing beds as outpatient “excluded services” separately from the swing bed stay even though the CAH swing bed is not paid under SNF PPS, and is therefore exempt from the SNF consolidated billing rules.
CAHs are exempt from using the list of Major Categories for SNF Consolidated Billing and therefore, should not separately bill the patient for outpatient services when they are provided while the patient is in a swing bed. Services provided to the patient during a covered Part A swing bed stay must be billed on the swing bed claim using TOB 18X and the patient is not responsible for any Part B coinsurance and deductible. You can research these citations in their entirety for more information.
- Social Security Act §1888(e)(7)
- Social Security Act §1883(b)(3)
- 42 CFR § 413.114
- 42 CFR § 483.20
- MLN Matters SE0606
- CMS Swing Bed Fact Sheet published in November 2011 – refer to the 2nd page under the section “Swing Bed Services Payments” for verification of this; however, this is not stated clearly. .
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