11503

Reason code 11503 indicates that the qualifying hospital stay is not within 30 days of the skilled nursing facility (SNF) (21x, 18x, 28x, 51x) admission date (occurrence code 70 span thru date is more than 30 days prior to SNF admit date). This edit will also assign on subsequent 183, 184, 213, and 214 type of bills (TOBs) where the initial 182 and 212TOB received reason code 11503.

The edit will also assign on SNF subsequent claims when the initial SNF claim TOB (180 or 210) rejected with reject code 11503 on claim page 6.

Resources/tips to avoid or correct this return to provider (RTP) code
In order to qualify for post-hospital extended care services, the individual must have been an inpatient of a hospital for a medically necessary stay of at least three consecutive calendar days and transferred within 30 days after discharge from the hospital. In certain circumstances the 30-day period may be extended – medical appropriateness exception. Verify the information on your claim and resubmit appropriately.

The Centers for Medicare & Medicaid Services (CMS) Publication 100-02, Chapter 8, section 20.2.2 - Medical appropriateness exception states:

“An elapsed period of more than 30 days is permitted for SNF admissions where the patient’s condition makes it medically inappropriate to begin an active course of treatment in a SNF immediately after hospital discharge, and it is medically predictable at the time of the hospital discharge that he or she will require covered care within a pre-determinable time period. The fact that a patient enters a SNF immediately upon discharge from a hospital, for either covered or non-covered care, does not necessarily negate coverage at a later date, assuming the subsequent covered care was medically predictable."

Resolution
If the qualifying hospital stay dates are correct and one of the following conditions applies, add the appropriate condition code.

  • Condition code 55 - The patient's SNF admission was delayed more than 30 days after discharge from the hospital because an SNF bed was not available
  • Condition code 56 - The patient's SNF admission was delayed more than 30 days after discharge from the hospital because the patient’s condition made it inappropriate to begin active care within that period
  • Condition code 57 - The patient previously received Medicare-covered SNF care within 30 days of the current SNF admission
  • Condition code 58 - Terminated Medicare + Choice Organization Enrollee

Resource
CMS Internet-only manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 6, SNF Inpatient part A Billing and SNF Consolidated Billing.

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