(Medicare Claims Processing Manual)

10.4.2 - SNF and Supplier Responsibilities  (Rev. 412, Issued: 12- 23-04, Effective: 05 -21-04, Implementation: 01- 24-05)  Problems involving the absence of a valid arrangement between an SNF and its suppliers typically tend to arise in one of the following two situations.   Problem Scenario 1:  An SNF elects to utilize an outside supplier to furnish a type of service that would be subject to Part A consolidated billing, but then fails to inform the supplier that the resident receiving the service is in a covered Part A stay.  This causes the supplier to conclude mistakenly that the service it furnishes to that resident is not subject to consolidated billing.  Based on the inaccurate impression that the residents SNF stay is noncovered, the supplier inappropriately submits a separate Part B claim for the service, and may also improperly bill other insurers and the resident.  Then, the supplier only learns of the actual status of the residents Medicare-covered SNF stay when that Part B claim is denied.  In this scenario, even though the supplier made reasonable efforts to ascertain from the SNF both the beneficiarys status as an SNF resident and the specific nature of the beneficiarys SNF stay, the information from the SNF (on which the supplier relied) proved to be inaccurate.   While we recognize that inadvertent errors may occasionally occur in the course of furnishing such information, an SNF should not only make a good faith effort to furnish accurate information to its supplier, but must reimburse the supplier once such an er ror is called to its attention.  If, in the scenario at issue, the SNF refuses to pay the supplier for the service even after being apprised of the inaccuracy of its initial information, the SNF would not be in compliance with consolidated billing requirem ents.  As discussed previously, having supporting documentation in place for the disputed service would not only help to ensure compliance with the consolidated billing requirements, but should also provide a vehicle for resolving the dispute itself.  Of course, the SNF can often prevent such disputes from arising to begin with, simply by ensuring that the supplier receives accurate and timely information about the status of a residents Medicare -covered SNF stay.  The SNFs responsibility to communicat e accurate and timely resident information to its suppliers is especially important in those instances where a particular portion of an otherwise bundled service remains separately billable to Part B (for example, the professional component that represents  a physicians interpretation of an otherwise bundled diagnostic test).  Problem Scenario 2:  A resident temporarily departs from the SNF on a brief leave of absence, typically accompanied by a relative or friend.  While briefly offsite, the resident (or the relative or friend, acting on the residents behalf) obtains services that are subject to the consolidated billing requirement, but fails to notify the SNF.  The SNF refuses to pay for the offsite services, and the supplier bills the beneficiary/family member directly.   As in the previous scenario, the SNF remains responsible for any services included in the SNF bundle of services subject to consolidated billing that are furnished to the resident by an outside entity, even in the absence of a valid arrangement with the SNF.  The SNFs can act to prevent such problems from arising by ensuring that each resident (and, if applicable, his or her representative) is fully aware of the applicable requirements.  For example, while the Medicare law at 1802 of the Act guarantees a benef iciarys free choice of any qualified entity that is willing to furnish services to the beneficiary, in selecting a particular SNF, the beneficiary has effectively exercised this right of free choice with respect to the entire package of services for which  the SNF is responsible under the consolidated billing requirement, including the use of any outside suppliers from which the SNF chooses to obtain such services.  SNF staff need to communicate these requirements to beneficiaries and family members upon ad mission.  Further, in providing such advice periodically throughout each residents stay, the SNF should take particular care to include any resident who is about to leave the facility temporarily, in order to ensure that the resident (and, if applicable, the residents representative) understands the need to consult the SNF before obtaining any services offsite.   Moreover, while the SNF itself should take reasonable steps to prevent such problems from arising, the supplier in this scenario is also responsible for being aware of and complying with the consolidated billing requirements.  This means that prior to furnishing services to a Medicare beneficiary, the supplier should routinely ascertain whether the beneficiary is currently receiving any comprehensive Medicare benefits (such as SNF or home health benefits) for which Medicare makes a bundled payment that could potentially include the suppliers services.  If the supplier ascertains that a particular beneficiary is, in fact, a resident of an SNF with which the supplier does not have a valid arrangement in place, then the supplier should contact the SNF before actually furnishing any services to that beneficiary that are subject to the consolidated billing provision.  Further, under the regulations at 42 CFR 489.21(h), the beneficiary cannot be charged for the bundled services.  20 - Services Included in Part A PPS Payment Not Billable Separately by the SNF  (Rev. 2573, Issued: 10- 26-12, Effective: 04-01-13, Implementation: 04 -01-13)  For cost reporting periods beginning on and after July 1, 1998, SNF services paid under Part A include posthospital SNF services for which benefits are provided under Part A, and all items and services which, prior to July 1, 1998, had been paid under Part B but furnished to SNF residents during a Part A covered stay regardless of source, except for the exclusions listed in the annual SNF consolidated billing update files.  Annual update files, as well as subsequent quarterly updates to the annual update, for SNF consolidated billing can be found at http://www.cms.hhs.gov/SNFConsolidatedBilling/.  This file lists services by HCPCS code, short descriptors, and the major category under which the HCPCS falls.  HCPCS added or removed by subsequent quarterly update transmittals will be listed under the respective years annual update at the above link.  The respective years annual update file will be updated to add or remove the HCPCS listed in the quarterly updates.  A general explanation of the five major categories can also be found at the above link.  NOTE:  It is important for MACs/providers to understand the major categories for SNF CB.  Some major categories exclude services by revenue code (see section 20.1.2.2 for emergency room exclusion) as well as bill types (see section 20.2.1.2 on coding for renal dialysis facilities and 20.2.2 for hospice facilities).   Services paid under Part A cannot be billed under Part B.  Any service paid under Part A that is billed separately will not be paid separately, or payment will be recovered if already paid at the time of the SNF billing.  The following subsections list the  types of services that can be billed under Part B for SNF residents for whom Part A payment is made.   20.1 - Services Beyond the Scope of the Part A SNF Benefit  (Rev. 846, Issued:  02- 10-06; Effective:  12 -15-05; Implementation:  03 -13-06)  The following services are beyond the scope of the SNF Part A benefit and are excluded from payment under Part A SNF PPS and from the requirement for consolidated billing.  These services must be paid to the practitioner or provider that renders them and a re billed separately by the rendering provider/supplier/practitioner to the A/B MAC (A) or (B).  The SNF may not bill excluded services separately under Part B for its inpatients entitled to Part A benefits.  HCPCS procedure codes representing these excepted services for services billed to the A/B MACs (A), (B), (HHH), and DME MACs  are updated as frequently as quarterly on the CMS Web site at :  https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/  Physicians, non-physician practitioners, and suppliers billing the A/B MAC (B) should consult the above link for lists of separately billable services.    Note :  There are separate Annual Update files for service billed to A/B MACs (B)/DME MACs and services billed to A/B MACs (A) or (HHH) posted to the Web site mentioned above.  20.1.1 - Physicians Services and Other Professional Services Excluded From Part A PPS Payment and the Consolidated Billing Requirement  (Rev. 12283, Issued:10- 05-23, Effective:01-08-24, Implementation:01-08-24)  Except for the therapy services (see 20.5), physicians professional services and services of certain nonphysician providers listed below are excluded from Part A PPS payment and the requirement for consolidated billing, and must be billed separately by the practitioner to the A/B MAC (B).  See below for Rural Health Clinic (RHC)/Federally Qualified Health Center (FQHC) instructions.  For this purpose physician service means the professional services of the physician as defined under the Medicare physician Fee Schedule.  For services that contain both a technical component and a professional component, the technical component, if any, must be billed by the SNF for its Part A inpatients.  The A/B MAC (B) will pay only the professional component to the physician.  For example, the technical component of a diagnostic radiology test (representing the performance of the procedure itself) is subject to SNF CB, whereas the professional component (representing the physicians interpretation of the test results) is excluded and, thus, remains separately billable under Part B.     Physicians services other than physical, occupational, and speech language pathology services furnished to SNF residents;     Physician assistants, working under a physicians supervision;     Nurse practitioners and clinical nurse specialists working in collaboration with a physician;     Certified nurse -midwives;     Qualified psychologists ;   Marriage and family therapists;   Mental health counselors; and    Certified registered nurse anesthetists.    SNF CB excludes the categories of practitioner services described above, and this exclusion applies specifically to those professional services that ordinarily require performance by the practitioner personally (see the regulations at  42 CFR 411.15(p)(2)(i) and 415.102(a)(3) ).  This means, for example, that an otherwise bundled task (such as a routine blood draw) cannot be converted into an excluded physician service merely by having a physician perform it personally, as such a task does not ordinarily require performance by t he physician.  This exclusion also does not encompass services  that are performed by someone else as an incident to the practitioners professional service.  Such incident to services remain subject to SNF CB and, accordingly, must be billed to Medicare by the SNF itself (see 10.3).    Providers with the following specialty codes assigned by CMS upon enrollment with  Medicare are considered physicians for this purpose.  Some limitations are imposed by 1861(q) and (r)  of the Act.  These providers may bill their A/B MAC (B) directly.    Physician Specialty Codes  01  General Practice  02  General Surgery  03  Allergy/Immunology  04  Otolaryngology  05  Anesthesiology  06  Cardiology  07  Dermatology  08  Family Practice  10  Gastroenterology  11  Internal Medicine  Physician Specialty Codes  12  Osteopathic Manipulative Therapy  13  Neurology  14  Neurosurgery  16  Obstetrics Gynecology  18  Ophthalmology  19  Oral Surgery (Dentists only)  20  Orthopedic Surgery  22  Pathology  24  Plastic and Reconstructive Surgery  25  Physical Medicine and Rehabilitation  26  Psychiatry  28  Colorectal Surgery (formerly Proctology)  29  Pulmonary Disease  30  Diagnostic Radiology  33  Thoracic Surgery  34  Urology  35  Chiropractic  36  Nuclear Medicine  37  Pediatric Medicine  38  Geriatric Medicine  39  Nephrology  40  Hand Surgery  41  Optometry  44  Infectious Disease  46  Endocrinology  48  Podiatry  66  Rheumatology  69  Independent Labs  70  Multi specialty Clinic or Group Practice  76  Peripheral Vascular Disease  77  Vascular Surgery  78  Cardiac Surgery  79  Addiction Medicine  81  Critical Care (Intensivists)  82  Hematology  83  Hematology/Oncology  84  Preventive Medicine  85  Maxillofacial Surgery  86  Neuropsychiatry  90  Medical Oncology  91  Surgical Oncology  92  Radiation Oncology  93  Emergency Medicine  94  Interventional Radiology  98  Gynecological/Oncology  Nonphysician Provider Specialty Codes   99  Unknown Physician Specialty  42  Certified Nurse Midwife  43  Certified Registered Nurse Anesthetist,  Anesthesia Assistants (effective 1/1/89)  50  Nurse Practitioner  62  Clinical Psychologist  (billing independently)  68  Clinical Psychologist  89  Certified Clinical Nurse Specialist  97  Physician Assistant