(Medicare Claims Processing Manual)

Use separate error codes where (1) dates are within (A/B MAC (B) will reject claim) or (2) where dates overlap (A/B MAC (B) will automate a separate denial message to provider).   Bypass the edit in the following situations:    The 21x or 22x type of bill contains a cancel date.    The incoming claim from date equals the SNF 21x or 22x history claim discharge date or incoming through date equals the SNF 21x or 22x history claim admission date.  Effective for claims with dates of service on or after April 1, 2001, CWF implemented revisions on January 2, 2008 to bypass the edits 7258 and 7259 when a therapy claim with a date of service on or after April 1, 2001 is submitted and the date of service is within the From/Thru dates of an occurrence Span code date of 74 reported on a SNF inpatient claim 21x in history.  This will allow for services to be separately payable outside of SNF consolidated billing during non- covered periods in the SNF.  Effective for claims with dates of service on or after April 1, 2001, CWF implemented revisions on April 7, 2008 to modify the existing therapy edit for Part B claims processing for non -covered SNF stays to read claims history to look for a 21x (SNF Inpati ent) bill type that contains an Occurrence Code 22 (Date Active Care Ended) and a Patient Status Code 30 (Still patient or expected to return for outpatient services) where there is no subsequent 21x (SNF inpatient) bill type discharge claim from the same provider.  As therapy services provided in a SNF must be consolidated when a beneficiary is in either a covered or non- covered stay, CWF will reject claims with dates of service after the posted SNF claim containing Occurrence Code 22 (Date Active Care Ended) and Patient Status 30 (Still patient or expected to return for outpatient services) until a 21x (SNF inpatient) bill type discharge claim is processed.  The entity furnishing the therapy services must look to the SNF for reimbursement rather than the A/B MAC (A) or (B).  For claims processed on or after January 5, 2009, this edit shall no longer be functional.  A/B MACs (A) and (B) shall re- open and- re-process claims previously denied due to this edit when brought to their attention should they determine that the beneficiary was not in a SNF stay during the period the therapy service was rendered.   B. Edits 7260 and 7261 - Part B Claim Without Therapy Against an Inpatient SNF  Reject if a Part B claim is received with From/Thru Dates overlapping or are within the From/Thru Dates on an SNF Inpatient claim (21x).  If the SNF 21x claim on history has patient status 30 and  occurrence code 22 (Date Active Care Ended), use occurrence 22 date instead of the through date.  Use separate error codes where (1) dates are within (A/B MAC (B) will reject claim); or (2) where dates overlap (A/B MAC (B) will automate a separate denial message to provider).  Bypass the edit in the following situations:   The 21x history claim contains a cancel date.    The incoming A/B MAC (B) claim from date equals the SNF 21x history claim discharge date.  The incoming A/B MAC (B) claim through date equals the SNF 21x history claim admission date.   A diagnosis code in any position on the incoming claim is for renal disease.   The A/B MAC (B) claim contains ambulance codes per the files supplied to CWF in the annual and quarterly updates with modifiers other than N (SNF) in both the origin and destination on the same claim.   The A/B MAC (B) claim is a CANCEL ONLY (Action Code 4) claim.    The A/B MAC (B) claim is denied.    The A/B MAC (B) service has a Payment Process Indicator other than A (allowed).    The A/B MAC (B) claim contains only separately payable services per the files supplied to CWF in the annual and quarterly updates.  Effective for claims with dates of service on or after April 1, 2001, CWF implemented revisions on January 2, 2008 to bypass the edits 7260 and 7261 when a claim with a date of service on or after April 1, 2001 is submitted and the date of service is within the From/Thru dates with an occurrence Span code date of 74, 76, 77, 79, or M1 reported on a SNF inpatient claim 21x in history or the date of service is greater than the occurrence date on a SNF inpatient claim 21x in history with an occurrence code date of A 3, B3, or C3.  This will allow for services to be separately payable outside of SNF consolidated billing during non- covered periods in the SNF.   110.2.3 - Duplicate Edits  (Rev. 1757, Issued: 06- 19-09, Effective: 07 -20-09, Implementation: 07- 20-09)  Effective April 1, 2002, CWF implemented the following duplicate edits for A/B MAC (B) submitted claims.   A. Edit 7253 -  Part B Ambulance Claim Against an Outpatient Part B SNF Ambulance Claim on History   Reject if a Part B claim is received with ambulance codes per the files supplied to CWF in the annual and quarterly updates and the Date of Service equals the Date of Service on an outpatient Part B SNF (23x) claim with revenue code 54x (ambulance).   Bypass the edit if either the incoming or history claim contains any of the following situations:    The claim is a CANCEL ONLY (Action Code 4) claim.   The claim is denied.   The incoming claim payment process indicator is other than A (allowed).   B. Edit 7257 -  A/B MAC (B) or DME MAC  or A/B MAC (A) Part B Claim Against An Inpatient B SNF (22x) Claim on History   Reject as a duplicate claim if an A/B MAC (B) or DME MAC Part B claim or A/B MAC (A) Part B claim (12x, 13x, 14x, 23x, 33x, 71x, 73x, 74x, 75x, 76x, 83x or 85x) is received containing date of service, HCPCS code and modifier if present, equal to the date o f service, HCPCS code and modifier, if present, on an inpatient Part B SNF (221, 222, 223, 224 or 225) claim.  Bypass the edit if either the incoming or history claim contains any of the following situations:    The claim is a CANCEL ONLY (Action Code 4) claim.   The claim is denied.   HCPCS code is not present on the A/B MAC (A) claim.  The A/B MAC (B) Part B claim payment process indicator is other than A (allowed).   For the A/B MAC (B)/DME MAC claim only, the Part B claim contains only separately payable services per the files supplied to CWF in the annual and quarterly updates.  110.2.4 - Edit for Ambulance Services  (Rev. 1757, Issued: 06- 19-09, Effective: 07 -20-09, Implementation: 07- 20-09)  When a medically necessary transport from one SNF to another SNF occurs when the beneficiary is discharged from the first SNF and admitted to the second, this transport is included in consolidated billing.  The first SNF is responsible for the ambulance se rvice and the cost is included in the Part A rate.  It is not separately billable.  CWF will reject these services to the A/B MAC (B).  The A/B MAC (B) must deny the service with appeals rights.   Effective for claims with dates of service on or after April 1, 2001, CWF implemented revisions on January 2, 2008 to bypass edit 7275 when a claim with a date of service on or after April 1, 2001 is submitted and the date of service is within the From/Thr u dates with an occurrence Span code date of 74, 76, 77, 79, or M1 reported on a SNF inpatient claim 21x in history or the date of service is greater than the occurrence date on a SNF inpatient claim 21x in history with an occurrence code date of A3, B3, or C3.  This will allow for services to be separately payable outside of SNF consolidated billing during non-covered periods in the SNF.   110.2.5 - Edit for Clinical Social Workers (CSWs)  (Rev. 3481, Issued: 03- 18-16. Effective: 06 -20-16, Implementation: 06- 20-16)  Per the Balanced Budget Act, services provided by CSWs to beneficiaries in a Part A SNF stay may not be billed separately to the A/B MAC (B).  Payment for these services is included in the prospective payment rate paid to the SNF by the A/B MAC (A) .  Though the policy was in effect since April 1, 2001, there were no corresponding edits. With the April 2003 release, CWF implemented a new SNF consolidated billing edit to prevent payment to CSWs for services rendered to beneficiaries in a Part A SNF st ay.  Effective April 1, 2003, CWF established the new edit 7269 for services rendered to these beneficiaries with dates of service on or after April 1, 2001, for claims received on or after April 1, 2003.  Once CWF determines that a beneficiary is in a Part A s tay, prior to applying the edits that review procedure codes to determine if payment should be allowed, CWF will review the performing provider type of the submitting entity.  If the performing provider type is 80, CWF will reject the claim to the A/B MAC (B) or return an unsolicited response with new error code 7269.  The A/B MAC (B)  will then take the same adjustment and recovery action as for other rejects and unsolicited responses.  When A/B MACs (B)  receive the new reject code, they must deny the claim and use the following RA and MSN messages.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 96  RARC: N121  MSN: 13.10  Effective for claims with dates of service on or after April 1, 2001, CWF implemented revisions on January 2, 2008 to bypass edit 7269 when a claim with a date of service on or after April 1, 2001 is submitted and the date of service is within the From/Thr u dates with an occurrence Span code date of 74, 76, 77, 79, or M1 reported on a SNF inpatient claim 21x in history or the date of service is greater than the occurrence date on a SNF inpatient claim 21x in history with an occurrence code date of A3, B3, or C3.  This will allow for services to be separately payable outside of SNF consolidated billing during non-covered periods in the SNF.  110.2.6 - Edit for Therapy Services Separately Payable When Furnished by a Physician  (Rev. 1757, Issued: 06- 19-09, Effective: 07-20-09, Implementation: 07-20-09)  A number of therapy services are considered separately payable when provided by a physician and shall be paid separately by the A/B MAC (B).  However, these services are considered therapy when provided by a physical or occupational therapist and are subje ct to consolidated billing.  Effective for claims with dates of service on or after July 1, 2004, edits will be implemented in the claims processing system to correctly process claims for these services.  A complete list of these services can be found on the CMS website at https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/.  110.2.7 - Edit to Prevent Payment of Facility Fees for Services Billed by an Ambulatory Surgical Center (ASC) when Rendered to a Beneficiary in a Part A Stay  (Rev. 1911; Issued:  02-05- 10; Effective Date:  01 -01-08; Implementation Date:  07-06-10)