Rules for Critical Access Hospital Swing Beds

June 22, 2016
Medicare Web

by Debbie Mackaman, RHIA, CPCO, CCDS

Recently, I have received many questions about two different payment concepts in regards to swing bed services provided in CAHs. I thought this would be a good time to review each one of these and include some food for thought from a compliance perspective.

The first billing issue that a facility may run into is when a patient is in a covered swing bed stay and requires a minor surgery for a condition that caused the swing bed stay or arose during the swing bed stay.

Just like in a SNF, and to be considered a covered swing bed stay, a patient must have been an inpatient in an acute care hospital for a minimum of three consecutive days (three midnights) within the 30 days prior to the swing bed admission. In addition, the skilled services must be related to a condition for which the patient received inpatient hospital services, or a different condition which develops during the appropriate swing bed stay.

In comparison, a CAH is reimbursed under the cost-based payment methodology rather than under the SNF PPS system. The latter allows separate payment to other providers under Part B for certain services that are considered excluded from the SNF Part A payment (i.e., operating room (OR), chemotherapy, dialysis).

Swing bed services provided in a CAH are not subject to SNF consolidated billing requirements, nor are they allowed to separately bill Part B for excluded services found in the SNF Major Categories Consolidated Billing List. During the swing bed stay, the CAH should not separately bill for outpatient ancillary services on TOB 0851 and patients are not responsible for Part B deductible and coinsurance. All services provided to the patient must be billed on the swing bed claim using TOB 018X to be reimbursed under cost. 

So what happens when a patient in a CAH’s swing bed requires a medically necessary minor outpatient surgery that does not necessitate a discharge from swing and readmission to acute care, nor meet the definition of a Leave of Absence? An example of this would be a patient who is in a covered swing bed stay for skilled services related to diabetes complications. During the swing stay, the patient requires a toe amputation that is performed in the CAH’s OR. This service would normally be reported under revenue code 036X; however, this revenue code series is not allowed on a TOB 018X, in addition to related revenue codes such as anesthesia and recovery room, since this type of service would not normally be performed in a SNF.

I have inquired with CMS on how to appropriately report this procedure on the CAH swing bed claim and bypass the automated claims processing edits. Unfortunately, CMS only confirmed that “there doesn’t seem to be CAH-specific guidance specifically for this issue. However, the CAH should include the related surgery on its swing-bed claim, based this off of Chapter 6 of the Medicare Claims Processing Manual, section 20.1.2.1.”

To view the complete, detailed article that appeared on Medicare Compliance Watch, click here.