Condition Codes 20 and 21 (SNF Providers)

If the Fiscal Intermediary receives a completely non-covered claim without either a condition code 20 or a condition code 21, the claim will be processed through the system. All non-covered claims must be processed as provider liable unless occurrence code 32 and date is present signifying that an advance beneficiary notice (ABN) was given to the beneficiary on that date, or, unless the service is non-covered by statute.

If a beneficiary demands a Medicare determination for any line(s) for other than Home Health services, the provider should put those line(s) on a separate bill showing the charges as non-covered and put condition code 20 on the bill. If a beneficiary wants an MSN for denial reasons on any line(s) for other than Home Health services, put those line(s) on a separate bill and show condition code 21 on that bill. The Standard System will generate denial reasons for the lines containing non-covered charges.

Note: The use of occurrence code 32 should be made specific to all claim types except Home Health bills. Since there is only one occurrence (32) to indicate the date the beneficiary received an ABN, only lines for which you notified the beneficiary on the same date may be submitted on the same bill for both demand bills and billing for denial bills (condition codes 20 and 21). If you gave ABNs on different dates for different procedures, shoe the services and the dates you gave ABNs on separate for each date involved.

These instructions will become effective and will be implemented for claims with dates of service on and after January 1, 2003.

Program Memorandum A-02-071, CR 2154