CMS Pub. 100-04, ch. 6, § 50.2

Beneficiaries admitted before the effective date of the denial of payment and taking

temporary leave, whether to receive inpatient hospital care, outpatient services or as

therapeutic leave, are not considered new admissions, and are not subject to the denial of

payment upon return. This policy applies even if there are multiple hospitalizations and

returns to the SNF during the period sanctions are in effect.

When determining if the beneficiary was admitted prior to the imposition of the ban, the

actual status of the beneficiary rather than the primary payor is the determining factor.

Therefore, there may be situations where the beneficiary is a private pay patient or a dual

eligible who was receiving Medicaid benefits prior to the imposition of the payment ban.

If this private pay patient or dual eligible goes to the hospital for needed care, and meets

the Medicare Part A criteria for SNF coverage upon return to the SNF, the readmission is

exempt from the denial of payment sanction. When billing for a readmission that is NOT

subject to the payment ban, providers must enter occurrence span code 80, Prior Same-SNF Stay Dates for Payment Ban Purposes, on the claim to identify the prior same-SNF

stay dates, in addition to reporting any LOA and prior hospital stay dates, using

occurrence span codes, that may affect the A/B MACs (A)’s determination of payment

ban exemption status. See Chapter 25 of this manual for occurrence span code titles and

definitions.