CJR Billing and the waiver of 3-day hospital stay requirement

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 American 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.

 CJR Model: SNF 3-Day Rule Wiaver