(Medicare Claims Processing Manual)

Formerly, bone mass measurement (screening) was listed as a preventive service excluded from SNF consolidated billing.  This was incorrect.  Such services are diagnostic, not screening, procedures, and therefore are bundled into SNF PPS payment and subject to consolidated billing.  20.5 - Therapy Services  (Rev. 2573, Issued: 10- 26-12, Effective: 04 -01-13, Implementation: 04- 01-13)  Therapy services are edited as inclusions, rather than exclusions, to consolidated billing.  Physical therapy, speech- language pathology services, and occupational therapy are bundled into the SNFs global per diem payment for a residents covered Part A s tay. They are also subject to the SNF Part B consolidated billing requirement (for services furnished to SNF residents during noncovered  stays) and must be billed by the SNF alone for its Part B residents on a 22x type of bill.  As noted in section 10.3 of this chapter, therapy services furnished to SNF residents remain subject to consolidated billing even when performed by a type of practitioner, such as a physician, whose services would otherwise be excluded (see section 1888(e) (2)(A)(ii) of the Social Security Act and the regulations at 42 CFR 411.15(p)(1)(i)).  Further, while most services either clearly fall within the category of therapy or clearly fall outside of it,  there are a few services (such as certain debridement codes) which, based on the specific type of practitioner involved, are sometimes considered therapy services and other times not.  However, because the consolidated billing provision focuses on the nature of the therapy service itself (rather than the type of practitioner who happens to be performing it), these sometimes therapy codes are always  considered therapy services in the specific context of SNF consolidated billing.   This means that a practitioner who furnishes such a service to an SNF resident must always look to the SNF itself (rather than to Part B) for payment.   SNF residents that fall below a Medicare skilled level of care may be moved out of the SNF or certified distinct part unit (DPU) to the Medicare non -certified area of the facility.  In doing so, the beneficiary is no longer subject to the SNF consolidated billing rule and therapy services may be billed directly to Medicare by the provider rendering the service or if billed by the SNF should be submitted on a 23x type of bill.  If the entire facility qualifies as a Medicare- certified SNF, all Part B therapie s must continue to be billed by the SNF on a 22x type of bill.  The CWF SNF CB therapy edit will be bypassed for 22x bill types that contain therapy services when those line item dates of service fall within a non-covered period reported on an inpatient 21x bill type.  For additional instructions, see Chapter 7, SNF Part B Billing, section 10.1.  In transmittals for A/B MAC (A) billing providing the annual update list of HCPCS codes affected by SNF consolidated billing, such services are referred to as Major Category V of SNF consolidated billing.  See section 10.1 above for the link to where transmittals providing curr ent lists of HCPCS codes used for Major Category V can be found.  20.6 - SNF CB Annual Update Process for A/B MACs (A)  (Rev. 3230, Issued: 04- 03-15, Effective: 06-15-15, Implementation: 06-15-15)  Barring any delay in the Medicare Physician Fee Schedule, CMS will provide the new Annual Update code file to CWF by November 1. Should this date change, CWF will be notified through the appropriate mechanism. All future updates will be submitted via a Recurring Update Notification form. These Recurring Update Notifications also describe how the changes will be implemented.  The CWF contractor shall compare the new code list for Major Categories I through V to the codes in the current edits. Codes that appear on the new list, but not in the current edit, shall be added to the edit.  CMS will make a determination as to which codes should be deleted from which edits. This mechanism will allow for any changes in professional component/technical component designations to be correctly coded for edits and for deleted codes and codes no longer valid for Medicare purposes as of the end of the calendar year, to continue to pay correctly for prior dates of service.  CMS will respond to the list provided by the CWF contractor and provide the determination on the codes to the CWF contractor.  The CWF contractor will delete codes from the edits per the CMS determination.   A/B MACs (A) , a term used to indicate both Part A and Part B institutional services, shall continue to respond to rejects and unsolicited responses received from CWF per current methodology.  A/B MACs (A)  shall reopen and reprocess any claims brought to their attention for services that prior to this update were mistakenly considered to be subject to consolidated billing and therefore, not separately payable.  A/B MACs (A)  need not search claims history to identify these claims.  Prior to January 1 of each year, a new code file will be posted to the CMS Web site at: http://www.cms.hhs.gov/SNFConsolidatedBilling/.  Should this date change, A/B MACs (A) will be notified through the appropriate mechanism.  Coding changes throughout the year may also be made as necessary through a quarterly update process.  As soon as the new code file is posted to the CMS Web site, through their Web sites and list serves, A/B MACs (A)  shall notify providers of the availability of the new file.   30 - Billing SNF PPS Services (Rev. 10880, Issued: 08- 06-21, Effective: 11 -08-21, Implementation: 11- 08-21)  SNFs and hospital swing bed providers are required to report inpatient Part A PPS billing data as follows.  Refer to the Medicare Claims Processing Manual, Chapter 25, Completing and Processing the Form CMS -1450 Data Set, for a description of claim data elements.    In addition to the required fields identified in Chapter 25, SNFs must also report occurrence span code 70 to indicate the dates of a qualifying hospital stay of at least three consecutive days which qualifies the beneficiary for SNF services.    Separate bills are required for each Federal fiscal year for admissions that span the annual update effective date (October 1).    Use Type of Bill 21X for SNF inpatient services or 18X for hospital swing bed services.    Revenue Code 0022.  This code indicates that this claim is being paid under the SNF PPS.  This revenue code can appear on a claim as often as necessary to indicate different HIPPS Rate Code(s) and assessment periods.    Effective for claims with dates of service on or after January, 1 2011, there must be an occurrence code 50 (assessment date) for each assessment period represented on the claim with revenue code 0022.  The date of service reported with occurrence code 50 must contain the ARD.  An occurrence code 50 is not required with default HIPPS code AAAxx (where xx equals varying digits) or ZZZZZ October 1, 2019 and after.  In addition, for OMRA related AIs 05, 06, 0A, 0B, 0C, 12, 13, 14, 15, 16, 17, 1A, 1B, 1C, 24, 25, 26, 2A, 2B, 2C, 34, 35, 36, 3A, 3B, 3C, 44, 45, 46, 4A, 4B, 4C, 54, 55, 56, 5A, 5B, 5C where 2 HIPPS may be produced by one assessment, providers need only report one occurrence code 50 to cover both HIPPS codes.  As of October 1, 2019, SNF PDPM changes are effective (see 120ff.).    HCPCS/Rates field must contain a 5 -digit HIPPS Code.  The first three positions of the code contain the RUG group and the last two positions of the code contain a 2 -digit assessment indicator (AI) code.  See Chapter 6 of the MDS RAI manual for valid RUG codes and AI codes.  As of October 1, 2019, SNF PDPM changes are effective (see 120ff.).    SNF and SB PPS providers must bill the HIPPS codes on the claim form in the order in which the beneficiary received that level of care.    Service Units must contain the number of covered days for each HIPPS rate code.   NOTE:  Fiscal Intermediary Shared System (FISS) requirement:   The sum of all covered units reported on all revenue code 0022 lines should be equal to the covered days field less the number of days reported in an OSC 77.  ( NOTE : The covered units field is utilized in FISS and has no mapping to the 837 or paper claim).   Total Charges should be zero for revenue code 0022.   When a HIPPS rate code of RUAxx, RUBxx, RUCxx, RULxx and/or RUXxx is present, a minimum of two rehabilitation therapy ancillary codes are required (revenue code 042x and/or, 043x and/or, 044x).  When a HIPPS rate code of RHAxx, RHBxx, RHCxx, RHLxx, RHXxx, RLAxx, RLBxx, RLXxx, RMAxx, RMBxx, RMCxx, RMLxx, RMXxx, RVAxx, RV Bxx, RVCxx, RVLxx, and/or RVXxx is present, a minimum of one rehabilitation therapy ancillary revenue code is required (revenue code 042x, 043x, or 044x.  Bills that are missing required rehabilitation therapy ancillary revenue codes are to be returned to the SNF for resubmission.  As of October 1, 2019, SNF PDPM changes are effective (see 120ff.).    The accommodation revenue code 018x, leave of absence is reported when the beneficiary is on a leave of absence and is not present at the midnight census taking time.    Principal Diagnosis Code -  SNFs enter the ICD -CM code for the principal diagnosis in the appropriate form locator.  The code must be reported according to Official ICD -CM Guidelines for Coding and Reporting, as required by the Health Insurance Portability and Accountability Act (HIPAA), including any applicable guidelines regarding the use of V codes for ICD -9.  The code must be the full ICD-CM diagnosis code, including all five digits (for ICD -9) or all seven digits (for ICD -10) where applicable.    Other Diagnosis Codes Required -  The SNF enters the full ICD -CM codes for up to eight additional conditions in the appropriate form locator.  Medicare does not have any additional requirements regarding the reporting or sequence of the codes beyond those c ontained in the ICD -CM guidelines.  30.1 - Health Insurance Prospective Payment System (HIPPS) Rate Code  (Rev. 10880, Issued: 08- 06-21, Effective: 11 -08-21, Implementation: 11- 08-21)  The HIPPS rate code consists of the three- character resource utilization group (RUG) code that is obtained from the Grouper software program followed by a 2- digit assessment indicator (AI) that specifies the type of assessment associated with the RUG code obtained from the Grouper. Providers may access the Resident Assessment Instrument (RAI) manual located at the following link for assessment- related issues: http://www.cms.gov/Medicare/Quality -Initiatives -Patient -Assessment -Instruments/NursingHomeQualityInits/index.html.  SNFs must use the version of the Grouper software program identified by CMS for national PPS as described in the Federal Register for that year.  The Grouper translates the data in the Long Term Care Resident Instrument into a case-mix group and assigns the correct RUG code. Effective for dates of service on or after October 1, 2010, the Grouper will automatically assign the 2 -digit AI.   Providers may access the following link for HIPPS code information: http://www.cms.hhs.gov/ProspMedicareFeeSvcPmtGen/02_HIPPSCodes.asp#TopOfPage   The above link includes documents that contain the complete list of RUG codes and AIs billed for Part A SNF stays.  Definitions and usage of each code are included.  In addition, a master file of all valid/termed HIPPS codes is provided.  The HIPPS rate code that appears on the claim must match the assessment that has been transmitted and accepted by the State in which the facility operates.  The SNF may bill the program only after:   An assessment has been completed and submitted to the State RAI Database;    A Final Validation Report indicating that the assessment has been accepted by the state; and    The covered day has actually been used.