SNF PDPM Claims Issue

The Centers for Medicare and Medicaid Services (CMS) has acknowledged a nursing home Medicare Part A billing issue when the first claim of a resident’s stay is filed out of sequence. Skilled nursing facilities (SNFs) with initial claims processed out of sequence are not being paid the correct Variable Per Diem (VPD)-adjusted rate under the Patient-Driven Payment Model (PDPM). Additionally, adjustment claims are not processing correctly. In order to calculate VPD correctly, claims need to process in order by date of service for each stay.

CMS intends to correct the issue in October. In the interim, SNF providers should:

• Make sure that claims are submitted in sequence and wait at least two weeks before billing subsequent claims
• When adjusting claims, cancel the initial claim and all subsequent claims in the SNF stay, then rebill in sequential order; or hold adjustments (when allowable) until October, when they will process correctly

To help avoid the problem, providers are encouraged to submit a complete bill at the time of entry.

Contact: Ken Allison, kallison@leadingageny.org, 518-867-8820