Skilled Nursing Facility Patient Driven Payment Model Billing For Noncovered Days With An Occurrence Span Code 76

The CR 11992 updated the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Sections 40.3.2 and 40.6 to include the following:

For claims that contain both covered days and noncovered days, and those noncovered days are the responsibility of the beneficiary (e.g., days submitted for noncovered level of care), the provider should append occurrence span code 76 to indicate the days the beneficiary is liable.

SNF claims that contain an OSC 76 greater than 3 days for a noncovered level of care will have a revenue code of 0022 line, which will correspond to an occurrence code 50 date (which is the date after the through date of the OSC 76). In these cases, the occurrence code 50 date will be utilized by the SNF pricer to reset the VPD adjustment to day one.

Claim Example:

Dates of Services: 10/09/2020–10/31/2020

OSC 76: 10/20/2020–10/25/2020

Occurrence code 50 date: 10/26/2020

This corresponds to the second line of the 0022 revenue code on the claim for the month of October

The VPD would reset to day one beginning on 10/26/2020.

The SNF provider will be paid for the dates 10/09/2020–10/19/2020 (day 1 –day 11) and 10/26/2020–10/31/2020 (day 1 – day 6).

* Appropriate use of the occurrence code 22 and the date are still required

Once the October claim is paid then any remaining claims would need to be billed in sequence i.e., 213.

The SNF provider needs to enter the correct OSC 76 for beneficiary liable days due to a level of care drop in order for the VPD to process correctly.

Skilled Nursing Facility Patient Driven Payment Model Billing For Noncovered Days With An Occurrence Span Code 76

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