Industry Insights

Claims for SNF CJR Patients May Require Special Code to Pay

December 2016
Author:  Cyndi Major

Cyndi Major

Senior Consultant II

Consulting

910 E. St. Louis Street, Suite 200
P.O. Box 1190
Springfield, MO 65801-1190 (65806)

Springfield
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The Centers for Medicare & Medicaid Services (CMS) released guidance on December 9, 2016, stating that claims submitted on or after January 1, 2017, for beneficiaries admitted to a skilled nursing facility (SNF) for care related to Comprehensive Care for Joint Replacement (CJR) will need to include demonstration code 75 in the claim form’s treatment authorization field when the qualifying hospital stay (QHS) criteria aren’t met and a waiver applies. This code will allow the claim to bypass the QHS edits and process for payment.

Under the CJR model, episodes begin with admission to an acute care hospital for a procedure that’s assigned upon beneficiary discharge to Medicare Severity-Diagnosis Related Group (MS-DRG) 469 or 470 and ends 90 days after the hospital discharge date.

A list of hospitals participating in the CJR model is updated monthly and can be found here.

Below is an excerpt from the CMS article that summarizes the circumstances to be met for the three-day stay to be waived for Part A SNF coverage:

When submitting claims to Medicare that require a waiver of the 3-day hospital stay requirement for Part A SNF coverage, SNF billing staff must enter a “75” in the Treatment Authorization Code Field. This allows MACs to appropriately pay SNFs treating beneficiaries during CJR Model episodes. In order to determine if use of the demonstration code “75” is appropriate, the following circumstances must be met:

  • The hospitalization does not meet the prerequisite hospital stay of at least 3 consecutive days for Part A coverage of ‘‘extended care’’ services in a SNF. If the hospital stay would lead to covered SNF services in the absence of the waiver, then the waiver is not necessary for the stay.
  • The discharge is from a participant hospital in the CJR model. Participant hospitals are listed on the CMS website this list is shared with the MACs on a monthly basis.
  • The beneficiary must have been discharged from the CJR model participant hospital for one of the two specified MS–DRGs (469 or 470) within 30 days prior to the initiation of SNF services.
  • The beneficiary meets the criteria for inclusion in the CJR model at the time of SNF admission: That is, he or she is enrolled in Part A and Part B, eligibility is not on the basis of ESRD, is not enrolled in any managed care plan, is not covered under a United Mine Workers of America health plan, and Medicare is the primary payer.
  • The waiver will apply if the SNF is qualified to admit CJR model beneficiaries under the waiver. A list of qualified SNFs will be sent to the MACs and Medicare Shared Systems Maintainers via a quarterly list, developed by CMS and posted to the CMS website on a quarterly basis. The list will contain those SNFs with an overall star rating of three stars or better for at least 7 of the preceding 12 months of the rolling data used to create the quarterly list.
  • The SNF must include Demonstration Code 75 in the Treatment Authorization field when submitting claims that qualify for the SNF waiver under the CJR model. Note: The waiver is not valid for swing bed (TOB 18X) stays or Critical Access Hospitals (CAHs).
  • All other Medicare rules for coverage and payment of Part A-covered SNF services continue to apply.

For more information, contact your BKD advisor.

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