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Related Change Request (CR) #: 3774
Related CR Release Date: April 29, 2005
Related CR Transmittal #: 540
Effective Date: April 29, 2005
Implementation Date: August 1, 2005
Providers Type Affected: Skilled nursing facilities (SNFs) and swing bed facilities billing Medicare fiscal intermediaries

Providers Action Needed:

STOP Impact to You

This article is informational only as CR 3774 is placing information in its Medicare Claims Processing Manual concerning the SNF Pricer. Effective for cost reporting periods beginning on or after July 1, 1998 all skilled nursing services billed on a 21x bill type are reimbursed based on calculations made with the SNF Pricer. Effective for cost reporting period beginning on or after July 1, 2002, all swing bed facility claims billed on an 18x bill type are be reimbursed on calculations made by the SNF Pricer.

CAUTION What You Need to Know

This instruction adds the SNF Pricer logic used to make payment determinations for SNF and swing bed (SB) prospective payment system (PPS) to Chapter 6, Section 30.6 (SNF PPS Pricer Software) of the Medicare Claims Processing Manual.

GO What You Need to Do

Review Chapter 6, Section 30.6 of the Medicare Claims Processing Manual if you for details regarding the SNF Pricer.

Background:

The Balanced Budget Act (BBA) of 1997 (Public Law 105-33) mandated the implementation of a per diem prospective payment system (PPS) for skilled nursing facilities (SNFs) that covers all costs (routine, ancillary, and capital) of covered SNF services furnished to beneficiaries under Part A of the Medicare program, effective for cost reporting periods beginning on or after July 1, 1998. Such claims are submitted on type of bill (TOB) 21X.

The Centers for Medicare & Medicaid Services (CMS) has previously developed an SNF Pricer program that calculates the Medicare payment rate for skilled nursing and swing bed facility services. (For cost reporting periods beginning on or after July 1, 2002, swing bed facility claims (TOB 18X) are reimbursed based on the calculations made by the SNF Pricer.)

The SNF Pricer is available electronically to the Medicare claims processing system and is updated at least annually. The SNF Pricer program can be found on CMS' website.

The purpose of CR 3774 is to revise Chapter 6 Skilled Nursing Facility Inpatient Part A Billing, of the Medicare Claims Processing Manual to add Section 30.6 Skilled Nursing Facility Prospective Payment System Pricer Software.

Please note that for SNF/SB units, SNF pricer logic sections have been added to the Medicare Claims Processing Manual (CPM) 100-04, Chapter 6, 30.6-30.7. If you wish to view the new 30.6-30.7 of Chapter 6 in the CPM immediately, you may reference the actual instruction or Change Request 3774 (see first link below). Alternatively to view the new sections when actual updates are applied to the CPM, you may also reference the link to Chapter 6 of the CPM below.

The actual instruction issued can be found on CMS' website.

The document Medlearn Matters Number MM3774 can be found on CMS' website.

Chapter 6 of the Claims processing manual.

Implementation:

The implementation date for this instruction is August 1, 2005.

Additional Information:

The revisions to Chapter 6 of the Claims Processing Manual are included in CR 3774. For complete details, please see the official instruction issued to your intermediary regarding this change.

From that web page, look for CR 3774 in the CR NUM column on the right, and then click on the file for that CR.

If you have questions regarding this issue, contact your intermediary on their toll free number.