US · guidance
CMS Pub. 100-04, ch. 6, § 40.8.1
SNF Spell of Illness Quick Reference Chart
Level of
Care
Patient's
Medicare
SNF Part A
Benefits Are
Exhausted
Patient Is
In
Medicare
Certified
Area of
the
Facility *
If in non-Medicare
Area, the
Facility Meets
the Definition
of a SNF **
Is the
Inpatient
Spell of
Illness
Continued?
Billing Action
Medicare
Skilled
YES YES N/A YES Submit Monthly Covered Claim.
NO YES N/A YES Submit Monthly Covered Claim.
YES NO YES YES Submit Monthly Covered Claim.
NO NO YES YES
Patient should be returned to certified area for Medicare to be
billed. Submit Monthly Covered Claim.
NO NO NO NO
Facility should determine whether it would be
appropriate to send patient back to a certified area for
Medicare coverage.
Not
Medicare
Skilled YES NO NO NO
Do not submit claim if pt came in non-skilled. Otherwise,
submit no-pay claim w/ discharge status code when patient
leaves the certified area.
YES YES N/A NO
Do not submit claim if pt came in non-skilled. Otherwise,
submit no-pay claim w/ discharge status code when patient
leaves the certified area.
NO YES N/A NO
Do not submit claim if pt came in non-skilled. Otherwise,
submit no-pay claim w/ discharge status code when patient leaves the
certified area.
NO NO YES NO
Do not submit claim if pt came in non-skilled. Otherwise,
submit no-pay claim w/ discharge status code when patient
leaves the certified area.
YES NO YES NO
Do not submit claim if pt came in non-skilled. Otherwise,
submit no-pay claim w/ discharge status code when patient
leaves the certified area.
* Whether the facility considers a patient's bed in the certified area to be a Medicare bed or not has no effect on whether the spell of
illness is continued and has no effect on the SNF's action.
** In some states, licensing laws for all nursing homes have incorporated requirements of the basic SNF definition (Social Security
Act §1819(a)(1)). When this is the case, any nursing home in such a state would be considered to meet this definition (see CMS
Internet-Only Manual, Pub. 100-7, Chapter 2, §2164 at www.cms.hhs.gov/manuals/ on the CMS website).
History
(Rev.4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
1f68c7e337c2885099868adb55cc82c35ef2dcbede51061345c19dfcd8fbf329
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