CMS Updates SNF PPS Consolidated Billing Exclusions Codes for CY 2023

Medicare; PPS; CMS
 


The Centers for Medicare and Medicaid Services (CMS) posted the list of payment codes excluded from Consolidated Billing (CB) requirements of the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS). There are 1,466 excluded codes for calendar year (CY) 2023. The list of codes added or deleted for CY 2023, including vaccine codes (Pneumococcal, Flu, Hepatitis B, or COVID-19), may be found here.    

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, including 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), and 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 
  • Radioisotope 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: