(Medicare Claims Processing Manual)

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: M28  MSN: 21.21  10.2  Billing for Outpatient SNF Services  (Rev. 229, Issued 07- 20-04 Effective/Implementation 08- 19-04) SNF -529  Coverage is available for all of the services described in 10.1.  However, beneficiaries not in the Medicare -certified Distinct Part Unit (DPU) are not required to have therapy services (physical therapy, occupational therapy, and speech language pathology) billed by the SNF.  Therapy services need o nly be bundled to the SNF for those SNF residents in a Medicare- certified DPU.  For additional information see Chapter 6, SNF Inpatient Part A Billing, 20.5 Therapy Services.  10.3 - Determining How Much to Charge Before Billing Is Submitted  (Rev. 1, 10- 01-03) SNF -529.1   The SNF may be able to determine from the SNF's records, from a transferring hospital, or from the patient the extent to which the Part B cash deductible is met.  The SNF may charge the patient for the unmet deductible and coinsurance.  The SNF should subm it a bill even if no payment can be made because the unmet Part B cash deductible exceeds the covered charges.  In addition, a bill is required when the SNF becomes aware that no bill has been submitted for covered services even though the time limitation for filing has expired.   10.4 - Charges for Services Provided in Different Accounting Years  (Rev. 1, 10- 01-03) SNF -529.2   The SNF must not put charges for services provided in different accounting years on the same bill.  At the end of the SNF's accounting  year, the SNF should submit a bill that contains the charges for all services furnished to the patient since the last bill through the end of the year.  The SNF should include bills in which the deductible covers all charges.  All services furnished in th e succeeding accounting year should be placed on a separate bill.  Complete all items on the subsequent bill.   10.5 - General Payment Rules and Application of Part B Deductible and Coinsurance  (Rev. 685, Issued: 09- 23-05, Effective: 12- 27-05, Implementatio n: 12 -27-05) SNF -529.3   Section 1888(e)(9) of the Social Security Act (the Act) requires that the payment amount for Part B SNF services shall be the amount prescribed in the otherwi se applicable fee schedule.  Thus, where a fee schedule exists for the type of service, the fee amount will be paid.  Where a fee does not exist on the Medicare Physician Fee Schedule (MPFS) the particular service is priced based on cost.  This is also true for all carrier -priced codes on the MPFS, but not for services paid on the Clinical Diagnostic Laboratory Fee Schedule.  All lab services missing fees are to be gap -filled.  Some specific services continue to be paid on a cost basis and are specificall y stated in the sections below where cost applies.   Where payment is made under a fee schedule, the beneficiary's deductible and coinsurance are based on the approved amount.  Where payment is made on a cost basis, deductible and coinsurance are based on c harges for the service.   20 - Use of Healthcare Common Procedure Coding System (HCPCS)  (Rev. 1, 10- 01-03) SNF -530, SNF -530.3   HCPCS is required for reporting all SNF services paid under Part B, whether paid by Medicare fee schedules or by some other mechanism.  A description of HCPCS codes is found in the Medicare Claims Processing Manual, Chapter 23.   The SNF should use the CPT -4 portion of HCPCS and/or Level II as directed by the manual sections applicable to the Part B service that is being billed.   Currently, HCPCS codes are not applicable on SNF Part A inpatient claims.   For Part B claims, there are separate codes for the technical component, professional component, and/or complete procedure.  Generally, SNFs bill for the technical component only, using the code that describes the procedure provided.   There may be specific rules for use of HCPCS codes for specific types of services (e.g., SNF's must bill global services for therapies).  These will be described in the manual sections for the applica ble service.   Revenue codes, HCPCS codes, line item dates of service, and units are required.  Charges must be reported by HCPCS code.  If the same revenue code applies to two or more HCPCS codes, the SNF should repeat the revenue code and show the line it em date of service, units and charge for each HCPCS code on a separate line.   30 - Billing Formats  (Rev. 3053, Issued: 08- 28-14, Effective: ICD -10: Upon Implementation of ICD -10 ASC- X12: 01- 01-12, Implementation ICD -10: Upon Implementation of ICD -10; ASC X12: 09- 30-14)  The SNF must use the current ASC X12 837 institutional claim format or if permissible Form CMS -1450 to bill for covered Part B services.  Instructions for those formats are located in the Medicare Claims Processing Manual, Chapter 25, "Compl eting and Processing the CMS -1450 Data Set."   30.1 - Frequency of Billing for Skilled Nursing Facilities (SNFs)  (Rev. 1, 10- 01-03) SNF -561  SNFs must bill repetitive Part B services on a single individual monthly bill (or at the conclusion of treatment).  This avoids Medicare processing costs in holding such bills for monthly review and reduces bill processing costs for relatively small claims.  See the Medicare Claims Processing Manual, Chapter 1, "General Billing Requirements," 50.2.2, for additional ins tructions when billing repetitive services and billing repetitive services during an inpatient stay.   Other one -time Part B services must be billed upon completion of the services.   30.2 - Guidelines for Submitting Corrected Bills  (Rev. 1, 10- 01-03) SNF -562, SNF -562.A   When a SNF or intermediary discovers an error on an original bill, there are three methods for correcting the bill depending on the type of error.  The SNF or intermediary may submit a late charge bill, an adjustment request, or maintain a lo g of charges.  Each of the methods and appropriate use are explained in the Medicare Claims Processing Manual, Chapter 1, "General Billing Requirements," 130.   40 - Billing Part B Rehabilitation Services  (Rev. 1, 10- 01-03) SNF -515.6   Part B rehabilitation services other than audiology services must be billed by the SNF for Part A inpatients, for Part B residents (those not in a covered Part A stay) and for outpatients.  Effective January 1, 1999, the MPFS is the payment basis for these  services.   The Medicare Claims Processing Manual, Chapter 5, "Part B Outpatient Rehabilitation and CORF Services," contains instructions for billing, payment, and applicable HCPCS codes.   40.1 - Audiologic Tests (Rev. 980, Issued: 06- 14-06, Effective: 10- 01-06, Implementation: 10- 02-06)  Audiologic tests will generally be billed to the carrier by the provider of service.  For tests that include both a professional component and technical component, the SNF may elect to bill the technical component to th e intermediary, but is not required to bill the service.  See Pub 100- 02 chapter 15, section 80.3 for further information on audiology.   Payment to SNFs for audiologic tests are bundled into the PPS payment amount for beneficiaries in a covered SNF Part A stay, whether provided directly by the SNF or under arrangements by an independent provider based on a contract with the SNF.  Independent audiologists may bill the carrier directly for services rendered to beneficiaries not  in a SNF Part A covered stay.  For beneficiaries not in a covered Part A SNF stay, who are sometimes referred to as beneficiaries in a Part B SNF stay, audiologic tests are payable under Part B when billed by the SNF as type of bill 22X, or when billed directly to the carrier by the pro vider of the service.  Payment is based on the Medicare Physician Fee Schedule (MPFS), whether by the carrier or the intermediary.   Since audiologic tests are not  bundled with speech - language pathology services, payment is made to the provider of service or to the SNF where the services are provided under arrangements with the SNF for SNF outpatients.  50 - Billing Part B Radiology Services and Other Diagnostic Procedures  (Rev. 1, 10- 01-03)  Acceptable HCPCS codes for radiology and other diagnostic service s are taken primarily from the CPT -4 portion of HCPCS.  Payment is the lower of billed charges or the fee schedule amount.  In either case, any applicable deductible and coinsurance amounts are subtracted from the payment amount prior to payment.  Coinsura nce is calculated on the Medicare payment amount after the subtraction of any applicable deductible amount.   Additional instructions for coverage, billing, payment, and specific instructions for the services listed below are found in the Medicare Claims Pr ocessing Manual, Chapter 13, "Radiology Services":    Contrast material other than low osmolar contrast material (LOCM) for radiology;   LOCM;   Radiopharmaceuticals;   IV Persantine;   Transportation of equipment;   Position Emission Tomography (PET); and   Adenosine.   50.1 - Bone Mass Measurements  (Rev. 1, 10- 01-03) SNF -535.5   Sections 1861(s)(15)  and 1861(rr)(1)  of the Act (as added by 4106 of the Balanced Budget Act (BBA) of 1997) standardized Medicare coverage of medically necessary bone mass measurements by providing for uniform coverage under Medicare Part B.  This standardized coverage is effective for claims with dates of service furnished on or after July 1, 1998.  The Medicare Claims Processing Manual, Chapter 13, "Radiology Services," contains coverage, billing, and payment requirements for bone mass measurements.   60 - Billing for Durable Medial Equipment (DME) , Orthotic/Prosthetic Devices, and Supplies (including Surgical Dressings)  (Rev. 3053, Issued: 08- 28-14, Effective: ICD -10: Upon Implementation of ICD -10 ASC- X12: 01- 01-12, Implementation ICD -10: Upon Implementation of ICD -10; ASC X12: 09 -30-14)  A SNF may  not bill for DME furnished to its Part A inpatients as necessary DME must be supplied to the beneficiary as part of SNF services.  A SNF may not bill for DME furnished to its Part B inpatients or outpatients.  However, a SNF may qualify as a supplier and enroll with the National Supplier Clearinghouse.  In such cases, the SNF is given a separate supplier number to bill outpatient DME to the DME MAC.  The DME MAC will furnish billing guidelines and payment will be made directly to the SNF as a supplier.  The SNF or other entity that furnishes prosthetic and/or orthotic devices to SNF residents for whom Part A benefits are not payable (no Part A entitlement or benefits exhausted) and for SNF outpatients may bill for such items.  The SNF bills the A/B MAC (A ).  Suppliers bill the A/C MAC (B) or DME MAC.  See Chapter 20 for DMEPOS billing requirements, including definition of "supplier."   Prosthetic and orthotic devices are:    Prosthetic devices (other than dental) that replace all or part of an internal body organ (including connective tissue) or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ, including replacement or repair of such devices (see the Medicare Benefit Policy Manual, Chapter 15, "Covered Medi cal and Other Health Service," 120); and    Leg, arm, and neck braces, trusses, and artificial legs, arms, and eyes, including adjustments, repairs, and replacement required because of breakage, wear, loss, or a change in the patient's physical condition (s ee the Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Health Service," 130).   SNFs bill supplies to its A/B MAC (A) for outpatients.   60.1 - Billing (Rev. 3053, Issued: 08- 28-14, Effective: ICD -10: Upon Implementation of ICD -10 ASC- X12: 01- 01-12, Implementation ICD -10: Upon Implementation of ICD -10; ASC X12: 09 -30-14)