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COVID-19 CMS SNF Billing Waivers and Guidance

Shasta McClary

August 26, 2020


Using the authority under section 1812(f) of the Social Security Act, CMS is waiving the requirement for a 3-day prior hospitalization for coverage of a SNF stay, which provides temporary emergency coverage of SNF services without a QHS, for those people who experience dislocations, or are otherwise affected by COVID-19. In addition, for certain beneficiaries who recently exhausted their SNF benefits, the waiver authorizes a one-time renewal of benefits for an additional 100 days of Part A SNF coverage without first having to start a new benefit period (this waiver will apply only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances).

  • The Secretary of the Department of Health and Human Services authorized waivers of both the Skilled Nursing Facility 3-day qualifying stay and the new spell of illness requirement under the Section 1135 of the Social Security Act retroactive to March 1, 2020.
  • The Secretary issued a broad based “blanket” waiver thus eliminating the requirement for a SNF to obtain a provider specific waiver.
  • Both waivers are intended to keep acute care hospital beds open and available as COVID 19 cases increase nationwide.

3-Day Qualifying Stay Waiver

Medicare Beneficiaries who are affected by this emergency will be able to use their Medicare Part A SNF

benefits without having a 3‐day qualifying hospital stay. Circumstances where this waiver may apply:

  • Beneficiary may be discharged from a hospital early and without three consecutive inpatient days
  • A Beneficiary may be admitted directly from home and skip the hospital stay entirely
  • A Beneficiary may be admitted directly from the hospital ER without three consecutive inpatient days
  • A current SNF patient who has days available in their spell of illness may “skill in place” without the need for a three hospital stay

New Benefit Period Waiver

  • Beneficiaries who exhaust their SNF benefits can receive a renewal of SNF benefits under the waiver except in one particular scenario (see bold script below)
  • To qualify for the benefit period waiver, a beneficiary’s continued receipt of skilled care in the SNF must in some way be related to the PHE.
    • One example would be when a beneficiary who had been receiving daily skilled therapy, then develops COVID-19 and requires a respirator and a feeding tube.
  • Beneficiaries who do not themselves have a COVID-19 diagnosis may nevertheless be affected by the PHE; for example, when disruptions from the PHE cause delays in obtaining treatment for another condition.
  • Would not apply to those beneficiaries who are receiving ongoing skilled care in the SNF that is unrelated to the emergency – a scenario that would have the effect of prolonging the current benefit period and precluding a benefit period renewal even under normal circumstances.
    • For example, if the patient has a continued skilled care need (such as a feeding tube) that is unrelated to the COVID-19 emergency, then the beneficiary cannot renew his or her SNF benefits under the section 1812(f) waiver as it is this continued skilled care in the SNF rather than the emergency that is preventing the beneficiary from beginning the 60 day “wellness period.”
  • In making such determinations, a SNF resident’s ongoing skilled care is considered to be emergency-related unless it is altogether unaffected by the COVID-19 emergency itself (that is, the beneficiary is receiving the very same course of treatment as if the emergency had never occurred).
    • This determination basically involves comparing the course of treatment that the beneficiary has actually received to what would have been furnished absent the emergency.
    • Unless the two are exactly the same, the provider would determine that the treatment has been affected by – and, therefore, is related to – the emergency.
  • Please note, as previously stated, ongoing skilled care in the SNF that is unrelated to the PHE does not qualify for the benefit period waiver. You must determine if the waiver applies in accordance with the criteria set forth above. If so:
    • Fully document in medical records that care meets the waiver requirements; this may be subject to post payment review.
    • Track benefit days used in the benefit period waiver spell and only submit claims with covered days 101 – 200.
    • Once the additional 100 days have been exhausted, follow existing processes to continue to bill Medicare no-pay claims until you discharge the beneficiary.
    • Identify no-pay claims as relating to the benefit period waiver by using condition code DR and including “BENEFITS EXHAUST” in the remarks field.

Billing Guidance

The following guidance provides specific instructions for using the QHS and benefit period waivers, as well as how this affects claims processing and SNF patient assessments.

To bill for the QHS waiver

  • Append the DR condition code.

To bill for the benefit period waiver:

  • Submit a final discharge claim on day 101 with patient status 01, discharge to home
  • Readmit the beneficiary to start the benefit period waiver.

For SNF benefit period waiver claims, include the following:

  • Condition code DR – identifies the claims as related to the PHE
  • Condition code 57 (readmission) – this will bypass edits related to the 3-day stay being within 30 days
  • COVID100 in the remarks – this identifies the claim as a benefit period waiver request.

MDS Assessment Guidance

For admission under the benefit period waiver:

  • Complete a 5-day PPS Assessment. (The interrupted stay policy does not apply.)
  • Follow all SNF Patient-Driven Payment Model (PDPM) assessment rules.
  • Include the HIPPS code derived from the new 5-day assessment on the claim.
  • The variable per diem schedule begins from Day 1.

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