July 2011 update to skilled nursing facility consolidated billing provision

Effective date: July 1, 2011
Implementation date: July 5, 2011

The Centers for Medicare & Medicaid Services (CMS) periodically updates the lists of HCPCS codes that are subject to the consolidated billing (CB) provision of the skilled nursing facility (SNF) prospective payment system (PPS.)

The SNF CB file reflects new codes that have been developed, and those that have been discontinued, for 2011, and any additions and deletions to categories of services excluded from CB. Please note that these new updates are required by changes to the coding system, not because the services subject to SNF CB are being redefined; nor will any additional services be added by these routine updates. Other regulatory changes beyond code list updates will be noted when, and if, they occur.

Medicare will pay SNF claims submitted to Medicare contractors for HCPCS codes only when they are included in SNF CB (in other words, do not appear on the exclusion list) Conversely, services excluded from SNF PPS and CB may be paid to providers (other than SNFs) for beneficiaries, even when in a SNF stay. Regardless, in order to assure proper payment in all settings, Medicare systems must edit for services provided to SNF beneficiaries both included and excluded from SNF CB. Further, SNF CB applies to non-therapy services, only when they are furnished to a SNF resident during a covered Part A stay; however, it applies to physical and occupational therapies and speech-language pathology services whenever they are furnished to a SNF resident, regardless of whether Part A covers the stay.

Impact to Part B providers

SNFs cannot “unbundle” services that are subject to CB to an outside supplier that can then submit a separate bill directly to the Part B carrier. Instead, the SNF itself must furnish the services, either directly, or under an “arrangement” with an outside supplier in which the SNF itself (rather than the supplier) bills Medicare.