Outpatient Therapy Services for Skilled Nursing - Revenue code 0420, 0430

Can I appeal an outpatient therapy threshold prior authorization decision?

Answer:

When a service provided beyond the thresholds is determined to be not medically necessary through prior authorization and/or pre-payment review of the claim, it is denied as a benefit category denial. No appeals can be submitted on prior authorization decisions, appeals can only be made on claims processed and denied for medical necessity. The resulting claim determination would be subject to the regular appeals process.

Outpatient therapy can be billed for occupational, physical and speech therapy rendered within the SNF.

• The individual therapist providing physical, occupational or speech therapies may not bill separately for services provided in the SNF.

• These services must not be billed during the same time frame as an inpatient claim.

• Outpatient services must be submitted on a separate claim from inpatient services.

• Outpatient therapy services should be billed with the following revenue codes:

o 0420 for physical therapy

o 0430 for occupational therapy

o 0440 for speech therapy



Outpatient Therapy

Type of bill (231-234)

Revenue codes (0420, 0430, 0440)

Skilled Nursing Facilities - Revenue code 0551, 0552

Revenue Codes

• Skilled Nursing

o 0551 – visit charge

o 0552 - hourly

• Indicate “21X”, “22X” or “23X” in type of bill field, which is field 4 for paper claims.

o First digit – Type of facility (2)

o Second digit – Bill classification (inpatient - 1, inpatient Medicare B only - 2 or outpatient - 3)

o Third digit – Frequency (e.g., admit thru discharge claim, etc.)


• Hospital Swing Bed claims should be billed with the “18X” type of bill and the taxonomy code for the hospital’s swing bed unit.

• For Florida Blue and BlueOptions members, provide the authorization/certification number on the claim. Plan of treatment should not be submitted with claim, unless requested.

• Submit room and board units to reflect the length of stay minus one unit for the discharge day. Day of discharge or death is not considered a covered day, unless admitted and discharged/deceased on the same day. For example, if a claim is submitted for dates of service 8/1/2014 to 8/7/2014, then the room and board units should be 6 to exclude the day of discharge or death.

• Refer to contractual reimbursement terms to determine if billing is based on Skilled Nursing Facility (SNF) revenue codes or HIPPS RUG codes. Typically only Medicare Advantage provider contracts are negotiated based on the inpatient prospective payment system for SNFs.

• Florida Blue requires SNF claims are submitted with the 191-194 or 199 revenue codes that represent sub-acute care. Any inpatient SNF claims for Non-BlueMedicare members that do not contain these specific room and board codes will be returned to the provider for appropriate billing.

Inpatient Care in SNF - Revenue code 0191 - 0194

Type of bill (211-214)

Revenue code (0191-0194, 0199)

• Level 1 (Revenue Code 0191)

• Level 2 (Revenue Code 0192)

• Level 3 (Revenue Code 0193)

• Level 4 (Revenue Code 0194)

• Level 5 (Revenue Code 0199)

• All per diem rates will include, but may not be limited to the following services:

• Semi-private room

• Meals (including special dietary requirements)

• Skilled nursing care

• Case management

• Medication and pharmacy supplies

• Routine laboratory

• Routine radiology (except when excluded based on the terms of the agreement)

• Nutrition services (including enteral feedings)

• Administration of medications including intramuscular and intravenous services

• Medical supplies

• Discharge planning

• DME (excluding specialized/high cost DME*)

• Quality assessment and improvement programming

• Occupational, physical and speech therapy


All codes billed other than the per diem revenue codes (0191-0194, 0199) will be denied as included in the per diems rates. If the referenced per diem revenue codes are not submitted on the claim, the claim will be denied. Exceptions include outliers, instances where Blue Plan coverage is secondary to Medicare and other specific instances defined in the member’s contract.

Participating SNFs can coordinate select medications with one of the pharmacy providers that are part of the SNF select medication program. These pharmacy providers will bill and be reimbursed directly for these services. Please refer to the Skilled Nursing Facility Select Medication Program section program details. Any services not included in the per diem rate should be delivered and billed by participating providers outside the SNF. Contact Care Coordination for a list of participating providers for these services.

*Certain DME may be considered Custom DME due to its modification for use by a particular member. The term Custom DME shall mean equipment that is significantly altered or uniquely manufactured to meet the specific needs of an individual member according to the description and orders a physician or licensed practitioner whose license permits such practitioner to order Custom DME.

Skilled Nursing Facility Coverage Requirements and Benefit Period

To qualify for Medicare Part A coverage of SNF services, the following conditions must be met:
◘ The beneficiary was an inpatient of a hospital for a medically necessary stay of at least 3 consecutive days;
◘ The beneficiary transferred to a participating SNF within 30 days after discharge from the hospital (unless the beneficiary’s condition makes it medically inappropriate to begin an active course of treatment in a SNF immediately after discharge and it is medically predictable at the time of the hospital discharge the beneficiary will require covered care within a predictable time period);
◘ The beneficiary requires skilled nursing services or skilled rehabilitation services on a daily basis. Skilled services must be:
■ Performed by or under the supervision of professional or technical personnel;
■ Ordered by a physician; and
■ Rendered for an ongoing condition for which the beneficiary had also received inpatient hospital services or for a new condition that arose during the SNF care for that ongoing condition;
◘ As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF; and
◘ The services delivered are reasonable and necessary for the treatment of the beneficiary’s inpatient illness or injury and are reasonable in terms of duration and quantity.

Benefit Period
Coverage for care in SNFs is measured in “benefit periods” (sometimes called a “spell of illness”). In each benefit period, Medicare Part A covers up to 20 days in full. After that, Medicare Part A covers an additional 80 days with the beneficiary paying coinsurance for
each day. After 100 days, the SNF coverage available during that benefit period is “exhausted,” and the beneficiary pays for all care, except for certain Medicare Part B services.
A benefit period begins the day the Medicare beneficiary is admitted to a hospital or SNF as an inpatient and ends after the beneficiary has not been in a hospital (or received skilled care in a SNF) for 60 consecutive days. Once the benefit period ends, a new benefit period
begins when the beneficiary has an inpatient admission to a hospital or SNF. New benefit periods do not begin due to a change in diagnosis, condition, or calendar year. Understanding the benefit period is important because SNFs must sometimes submit claims for which they do not expect to receive payment to ensure the benefit period is properly tracked in the Common Working File (CWF).

Medicare Part A Payment
The SNF Prospective Payment System (PPS) pays for all SNF Part A inpatient services. Part A payment is primarily based on the Resource Utilization Group (RUG) assigned to the beneficiary following required Minimum Data Set (MDS) 3.0 assessments. As a part of the
Resident Assessment Instrument (RAI), the MDS 3.0 is a data collection tool that classifies beneficiaries into groups based on the average resources needed to care for someone with similar needs. The MDS 3.0 provides a core set of screening, clinical, and functional status
elements, including common definitions and coding categories. It standardizes communication about resident problems and conditions.
General Payment Tips
• Medicare will not pay under the SNF PPS unless you bill a covered day.
• Ancillary charges are only allowed for covered days and are included in the PPS rate.

Medicare Part B Payment
Medicare Part B may pay for:
◘ Some services provided to beneficiaries residing in a SNF whose benefit period exhausted or who are not otherwise entitled to payment under Part A;
◘ Outpatient services rendered to beneficiaries who are not inpatients of a SNF; and
◘ Services excluded from SNF PPS and SNF consolidated billing.

Consolidated Billing Under the consolidated billing provision, SNF Part A inpatient services include all Medicare Part A services considered within the scope or capability of SNFs. In
some cases, the SNF must obtain some services it does not provide directly. For these services, the SNF must make arrangements to pay for the services and must not bill Medicare separately for those services.

Skilled Services

Skilled Nursing and skilled rehabilitation services are those services furnished pursuant to physician orders that:
•    Require the skills of qualified technical or professional health personnel, such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, and speech-language pathologists or audiologists; and
•    Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the beneficiary and to achieve the medically desire result.