The Centers for Medicare and Medicaid Services (CMS) posted April 2023 updates to the list of payment codes excluded from Consolidated Billing (CB) requirements of the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS).
CMS periodically updates the lists of HCPCS codes that are excluded from the CB provision of the SNF PPS. Services excluded from SNF PPS and CB may be paid to providers, other than SNFs, for patients, even when in a SNF stay. Medicare won’t pay for services not on the exclusion lists to any providers other than a SNF.
Background
In the Balanced Budget Act of 1997, Congress mandated that payment for most services provided to beneficiaries in a Medicare-covered SNF stay be included in a bundled prospective payment made through the Part A Medicare Administrative Contractor to the SNF.
Under CB requirements, the billing responsibility for the entire package of care that residents receive during a covered Part A SNF stay and physical, occupational, and speech therapy services received during a non-covered stay fall upon the SNF.
There are a limited number of services specifically excluded from consolidated billing, and therefore, separately payable to the SNF or other providers. These separately payable services include:
- Physician's professional services
- Certain dialysis-related services, including covered ambulance transportation to obtain the dialysis services
- Certain ambulance services, inlcuding:
- Ambulance services that transport the beneficiary to the SNF initially
- Ambulance services that transport the beneficiary from the SNF at the end of the stay (other than in situations involving transfer to another SNF)
- Roundtrip ambulance services furnished during the stay that transport the beneficiary offsite temporarily in order to receive dialysis, or to receive certain types of intensive or emergency outpatient hospital services
- Erythropoietin for certain dialysis patients
- Certain chemotherapy drugs
- Certain chemotherapy administration services
- Customized prosthetic devices
For Medicare beneficiaries in a non-covered stay, only therapy services are subject to consolidated billing.
More information about SNF CB requirements may be found in the links below: