Major Categories for Skilled Nursing Facility (SNF) Consolidated Billing
The SNF 2020 annual update file contains a comprehensive list of HCPCS codes involved in editing institutional claims submitted to A/B MACs for services subject to SNF consolidated billing (CB). The CMS has divided these codes into 5 Major Categories:
Major Category I – Exclusion of Services Beyond the Scope of a SNF
These services must be provided on an outpatient basis at a hospital, including a critical access hospital (CAH) only, not by a SNF, and are excluded from SNF PPS and CB for beneficiaries in Part A stay. Services directly related to these services, defined as services billed for the same place of service and with the same line item date of service as the services listed below, are also excluded from SNF CB, with exceptions as listed below
- In general, bypasses also allow CT Scans, Cardiac Catheterization, MRI, Radiation Therapy, Angiography, and Outpatient Surgery HCPCS codes 0001T – 0021T, 0024T – 0026T, or 10021 – 69990 (except HCPCS codes listed as inclusions under Major Category I.F) to process and pay. This includes all other revenue code lines on the incoming claim that have the same line item date of service (LIDOS).
Major Category I. is further broken down into subcategories:
A. Computerized Axial Tomography (CT) Scans
B. Cardiac Catheterization
C. Magnetic Resonance Imaging (MRIs)
D. Radiation Therapy
E. Angiography, Lymphatic, Venous, and Related Procedures
F. Outpatient Surgery and Related Procedures– INCLUSION
Inclusions, rather than exclusions, are given in this one case, because of the great number of surgical procedures that are excluded and can only be safely performed in a hospital operating room setting. It is easier to automate edits around the much shorter list of inclusions under this category, representing minor procedures that can be performed in the SNF itself. The physician’s service itself may be excluded for the codes listed (identified in the Carrier A/B MAC files) in this section, however, when these codes are billed by the hospital they are for the technical/facility charge and are not excluded.
G. Emergency Services
These services are identified on claims submitted to Part A MACs by a hospital or CAH using revenue code 045x (Emergency Room—“x” represents a varying third digit). Related services with the same line item date of service (LIDOS) are also excluded. Note that in order to get a match on the LIDOS there must be a LIDOS and HCPCS in revenue code 045x.
Note: In order to bypass services related to the ER encounter which are performed on subsequent service dates, hospitals must identify those services by appending a modifier ET (Emergency Services) to those line items. Please review Change Request 5389 for further information.
H. Ambulance Trips
With Application to Major Category II: Ambulance trips associated with Major Category I.A-E and G services are excluded from SNF CB. In addition, ambulance trips associated with Major Category II. A. services provided in renal dialysis facilities (RDFs) are also excluded from SNF consolidated billing.
I. Additional Surgery HCPCS –EXCLUSIONS
These services are additional surgery exclusions that do not fall within the Outpatient Surgery HCPCS codes ranges 0001T – 0021T, 0024T – 0026T, or 10021 – 69990 (except HCPCS codes listed as inclusions under Major Category I.F)
Major Category II – Additional Services Excluded when Rendered to Specific Beneficiaries
These services must be provided to specific beneficiaries, either: (A) End-Stage Renal Disease (ESRD) beneficiaries or (B) beneficiaries who have elected hospice, by specific licensed Medicare providers, and are excluded from SNF PPS and consolidated billing. SNFs will not be paid for Category II.A. Services (dialysis, etc.) when the SNF is the place of service, as to receive Medicare payment, these services must be provided in a renal dialysis facility. Hospices must also be the only type of provider billing hospice services. his category also excludes non-ESRD acute dialysis from SNF CB, as set forth in §20.2.1 of the Medicare Claims Processing Manual, Chapter 6.
A. Dialysis, EPO, Aranesp, and Other Dialysis Related Services for ESRD Beneficiaries
Specific coding is used to differentiate dialysis and related services that are excluded from SNF consolidated billing for ESRD beneficiaries in three cases: (1) when the services are provided in a RDF (including ambulance services listed under Major Category I. above), (2) home dialysis when the SNF constitutes the home of the beneficiary, and (3) when the drugs EPO or Aranesp are used for ESRD beneficiaries. Note that SNFs may not be paid for home dialysis supplies.
- Coding Applicable to Services Provided in a RDF or SNF as Home: Institutional dialysis services billed only by a RDF are identified by the type of bill 72X. ESRD beneficiaries billed by an RDF must be accompanied by the dialysis-related diagnosis code N18.6. The applicable HCPCS codes are identified in the excel file as Dialysis Supplies and Dialysis Equipment.
- Coding Applicable to EPO and Aranesp Services: Epoetin alfa (trade name EPO) is a drug Medicare-approved for use by ESRD beneficiaries. Darbepoetin alfa (trade name Aranesp) is a drug Medicare-approved for use by ESRD beneficiaries. When epoetin alfa or darbepoetin alfa are given by the dialysis facility in conjunction with dialysis, these drugs are excluded and must be billed by the RDF. Instructions for billing RDF services are located in publication 100-4, chapter 8. To distinguish epoetin alfa or darbepoetin alfa given to ESRD beneficiaries from the same drugs given to non-ESRD beneficiaries CMS has developed separate codes. The instructions for billing for non-ESRD epoetin alfa or darbepoetin alfa are located in publication 100-4, chapter 17, section 80.9. These drugs for non-ESRD use are always bundled to the SNF for beneficiaries in a covered Part A stay.
B. Hospice Care for a Beneficiary’s Terminal Illness
Hospice services for terminal conditions are identified with the following bill types: 81X or 82X.
Related Article: 2020 SKILLED NURSING FACILITY (SNF) EXCLUDED HCPCS CODES
Major Category III – Additional Excluded Services Rendered by Certified Providers
These services may be provided by any Medicare provider licensed to provide them, except a SNF, and are excluded from SNF PPS and consolidated billing. HCPCS code ranges for chemotherapy, chemotherapy administration, radioisotopes, and customized prosthetic devices are set in statute. This statute also gives the Secretary the authority to make modifications in the particular codes that are designated for exclusion within each of these service categories; accordingly, the minor and conforming changes in coding that appear in the instruction are made under that authority.
A. Chemotherapy
B. Chemotherapy Administration
Chemotherapy Administration codes listed with an asterisk (*) in the file are included in SNF PPS payment for beneficiaries in Part A stay when performed alone or with other surgery but are excluded if they occur with the same line item date of service as an excluded chemotherapy agent. A chemotherapy agent must also be billed when billing these services and physician orders must exist to support the provision of chemotherapy. Codes listed w/o an asterisk (*) are treated the same as those with an (*) for all providers except hospitals, including CAHs. Codes w/o an (*) are excluded surgery codes and may be billed w/o a chemotherapy agent in hospital settings only.
C. Radioisotopes and their Administration
D. Customized Prosthetic Devices
Major Category IV – Additional Excluded Preventive and Screening Services
These services are covered as Part B benefits and are not included in SNF PPS. Such services must be billed by the SNF for beneficiaries in Part A stay with Part B eligibility on type of bill (TOB) 22x. Swing Bed providers must use TOB 12x for eligible beneficiaries in a Part A SNF level. You can access Chapter 18 “Preventive and Screening Services” of the Claims Processing manual for coverage and billing guidance.
A. Mammography
B. Vaccines (Pneumococcal, Flu or Hepatitis B)
C. Vaccine Administration
D. Screening Pap Smear and Pelvic Exams
E.Colorectal Screening Services
F. Prostate Cancer Screening
G. Glaucoma Screening
H. Diabetic Screening
I. Cardiovascular Screening
J. Initial Preventative Physical Exam
K. Abdominal Aortic Aneurysms (AAA)Screening
Major Category V – Part B Services Included in SNF Consolidated Billing
Therapy services are included in SNF PPS and consolidated billing for residents in Part A stay and must be billed by the SNF alone for its Part B residents.
A. Therapies billed with revenues codes 42x (physical therapy), 43x (occupational therapy), 44x (speech-language pathology)
Effective management of the revenue cycle, from scheduling to payment, by certified, skilled professionals is the single most important factor to positively impact the financial health of an SNF. E2E Medical Billing Services has over 05 years of experience in providing comprehensive Skilled Nursing Facility (SNF) billing, coding, and other value-added services. Our SNF billing services will help you get your invoices paid, ensure reimbursements take place on time and do the necessary coordination and follow-up when there is a delay. To know more about our SNF billing and coding services call us at 888-552-1290 or email us at [email protected]