Skilled Nursing Facility Claims Hold

As the Centers for Medicare & Medicaid Services (CMS) has undertaken the implementation of the Patient-Driven Payment Model (PDPM), they are holding a limited number of Skilled Nursing Facility (SNF) claims while making further refinements to the claims processing system.
 
PDPM is an historic reform of the SNF prospective payment system. PDPM focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment. PDPM was effective on October 1, 2019.
 
Specifically, the CMS is holding claims with:
  • Dates of service October 1, 2019, or later, and
  • Type of Bill (TOB) inpatient services (21X) and swing bed services (18X) subject to SNF PDPM, and
  • Multiple line items, Health Insurance Prospective Payment System (HIPPS) codes, with different rate codes (revenue code 0022).
 
Typically, SNFs bill these claims on monthly cycles. Claims with single HIPPS codes were previously being held but are now being released for processing. The CMS anticipates releasing the remaining held claims in late November, once the CMS completes systems testing to ensure accurate and timely payment. As of November 1, less than 50 claims are being held.
 
In addition, the CMS underpaid some SNF inpatient services (21X) and swing bed services (18X) claims for dates of service in October 2019 with a single line item, single HIPPS code. The CMS is automatically reprocessing those claims; no provider action is needed.
 
The CMS will continue to provide updates as further information develops.
For more information or assistance with the topic of the skilled nursing facility claims hold, please contact Rick Snyder, Billing and Reimbursement Consultant, at rick.snyder@actcpas.com .