CMS Releases New Comprehensive CJR Model: SNF 3-Day Rule Waiver MLN Matters® Article

December 15, 2016
Health Policy

The Centers for Medicare & Medicaid Services (CMS) recently released a new MLN Matters Special Edition Article on Comprehensive Care for Joint Replacement (CJR) Model: Skilled Nursing Facility (SNF) 3-Day Rule Waiver. The article discusses the policies surrounding the use of the 3-day stay wavier available for use under the CJR model.

The CJR model waives certain existing payment system requirements to provide additional flexibilities to hospitals participating in CJR, as well as other providers that furnish services to beneficiaries in CJR episodes. The purpose of such flexibilities is to increase Lower Extremity Joint Replacement (LEJR) episode quality and decrease episode spending or provider and supplier internal costs, or both, and to provide better, more coordinated care for beneficiaries and improved financial efficiencies for Medicare, providers, and beneficiaries.

In order to provide more comprehensive care across the post-acute spectrum and support the ability of participant hospitals to coordinate the care of beneficiaries, CMS will conditionally waive the 3-day stay requirement for covered SNF services for beneficiaries in CJR episodes in performance years 2 through 5 of the CJR model (i.e. on or after January 1, 2017).

Under Medicare rules, in order for Medicare to pay for SNF services, a beneficiary must have a qualifying hospital stay of at least 3 consecutive days (counting the day of hospital admission but not the day of discharge).

CMS waives the SNF 3-day rule for coverage of a SNF stay for a CJR beneficiary following the anchor hospitalization, only if the SNF is identified on the applicable calendar quarter list of qualified SNFs at the time of CJR beneficiary admission to the SNF. CMS will determine all the qualified SNFs for each calendar quarter based on a review of the most recent rolling 12 months of overall star ratings on the Five-Star Quality Rating System for SNFs on the Nursing Home Compare website. All other Medicare rules for coverage and payment of Part A-covered SNF services continue to apply. This will allow payment of claims for SNF services delivered to beneficiaries at eligible sites.

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 click here to read the requirements and full article.