October Quarterly Update to 2016 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement
Provider Types Affected: This information is intended for physicians, providers, and suppliers submitting claims to all Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries who are in a Part A Skilled Nursing Facility (SNF) stay.
Provider Action Needed: This information is based on Change Request (CR) 9688 updates to the lists of Healthcare Common Procedure Coding System (HCPCS) codes that are subject to the consolidated billing provision of the SNF Prospective Payment System (PPS). Changes to Current Procedure Terminology (CPT)/HCPCS codes and Medicare Physician Fee Schedule designations will be used to revise CWF edits to allow MACs to make appropriate payments in accordance with policy for SNF consolidated billing in the “Medicare Claims Processing Manual,” Chapter 6, Section 20.6. Make sure your staffs are aware of these updates.
Background: The Centers for Medicare & Medicaid Services (CMS) periodically updates the lists of HCPCS codes that are excluded from the Consolidated Billing (CB) provision of the SNF PPS. Services excluded from SNF PPS and CB may be paid to providers, other than SNFs, for beneficiaries, even when in a SNF stay. Services not appearing on the exclusion lists submitted on claims to MACs, including Durable Medical Equipment MACs (DME).
Please note: “Shall” denotes a mandatory requirement, and “should” denotes an optional requirement.