Description:
The following policy addresses Blue Cross Blue Shield of North Dakota (BCBSND) policy and billing guidelines for inpatient skilled nursing facility claims.
Type of Service
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Definition
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Skilled Nursing Facility (SNF)
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A non-acute inpatient treatment center staffed with trained medical professionals. Typically, a SNF is a temporary residence for patients undergoing rehabilitation treatment.
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Per diem rate
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The payment rate associated with the Resource Utilization Group (RUG) category that the member classifies to, as determined by the North Dakota Department of Human Services, as stated in ND Century Code 50-24.4-06.
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Leave of Absence (LOA)
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A situation where the SNF resident is absent but not discharged, for reasons other than admission to a hospital, other SNF, or another portion of the same institution. A patient cannot be an inpatient in more than one facility at a time.
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Policy:
Skilled nursing facilities (SNF) submit inpatient services on the UB-04 Claim Form using the SNF’s National Provider Identifier (NPI) and are reimbursed at the per diem rate. SNFs must submit UB-04 Claim Forms using the correct Type of Bill (TOB) sequence to ensure correct claims processing:
- 211 – Admit through Discharge TOB
- 212 – Admit to end of 1st Month of TOB
- 213 – Monthly TOB following TOB 212 but prior to 214 TOB
- 214 – Discharge TOB
The per diem rate includes services such as:
- Room and board
- Speech, occupational and physical therapies
- Routine medical and nursing supplies including but not limited to ace bandages, dressings, catheter supplies, fleece pads, gastric feeding tube supplies, IV trays, ostomy supplies, oxygen and support stockings
- Routine durable medical equipment (DME) including but not limited to walkers, wheelchairs, humidifiers, gastric chairs and non-custom seating systems
- Over-the-counter items including but not limited to aspirin, antacids, laxatives, lotions and vitamins
- Influenza and pneumonia vaccines
BCBSND allows reimbursement over and above the per diem rate for the following services when the SNF includes them on the inpatient SNF claim along with the appropriate revenue codes.
- IV and SQ medication- submitted on revenue code 0636
- IV solution with medication admixed - submitted on revenue code 0636
- Specialized beds and mattresses - submitted on revenue code 0947
- Orthotics and prosthetics (e.g. splints, braces, artificial limbs) and, customized orthotics and prosthetics - submitted on revenue code 0274. Services for orthotics and prosthetics may be submitted by the SNF or the supplier.
- If the patient has no prescription drug benefit, prescription medication charges should be totaled and submitted on revenue code 0253.
Services that should not be submitted on the inpatient SNF claim include:
- When the patient has prescription drug benefits, the prescription medication supplied to the patient should be submitted to the Pharmacy Benefit Manager (PBM) if the benefit plan has this option.
- Over-the-counter medications are not separately reimbursable and should not be included in this revenue code.
- Any diagnostic services received, such as laboratory or x-ray services, should be submitted by the provider who rendered the service.
- If an ambulance transport is required, the ambulance provider must submit the claim for these services.
- Outpatient physical, occupational, and speech therapy services provided to patients who are not an inpatient of the SNF must be billed on the CMS-1500 using the therapists NPI.
If the patient has a leave of absence (LOA) during the inpatient stay, the LOA day(s) must be identified with Revenue Code 018X and units equal to the number of LOA days. The following are a couple examples on how to count LOA days:
- If the patient leaves the hospital on Saturday afternoon and returns on Sunday afternoon, there is no LOA as the patient received services on both days.
- If the patient leaves the hospital on Saturday afternoon and returns on Monday afternoon, one (1) LOA day should be billed.
- When a patient requires inpatient level of care at another medical center an LOA cannot be used. In this scenario, the date the patient left the facility would be the through date on the claim and the appropriate discharge status code must be reported. If the patient returns at an inpatient level of care, a new inpatient claim for the readmission would be submitted.
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
History:
Date
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Updates
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3/31/2020
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Created Inpatient Skilled Nursing Facility Billing reimbursement policy
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2/9/2022
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Added a definition for Leave of Absence and information that a patient cannot be inpatient at more than one facility at a time. Updated the formatting of the policy.
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2/9/2023
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Performed annual review of policy.
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