(Medicare Claims Processing Manual)

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)  The Balanced Budget Act (BBA) of 1997 required the implementation of a SNF prospective payment system and the consolidated billing of services provided to residents of the SNF.  Facility services provided by a freestanding non-hospital ASC are included under the SNF CB provisions.  This edit will prevent payment of those facility services when provided in an ASC to a beneficiary in a Part A SNF CB stay.  Effective for claims with dates of service on or after January 1, 2008 that are processed on or after July 6, 2010, when CWF receives a claim for a facility service from an ASC that is enrolled as a provider specialty type 49, and the service has a Type of Service F, and the patient is in a Part A SNF stay, it shall notify the A/B MACs (B) that they shall reject the claim line for the service(s).  It shall send the same trailer that is currently sent for services subject to SNF consolidated billing.  (The s ervices subject to this editing will also appear on the ASC Fee schedule.)   Also, when CWF receives a Part A SNF claim, it shall also notify A/B MACs (A), (B), or (HHH), and DME MACs through an unsolicited response of any facility services as described above that were incorrectly paid.  MACs shall follow current processes to recoup any overpayments.  A/B MACs (A), (B), (HHH), or DME MACs shall return the same messages found in Section 110.2.1C.  110.3 - CWF Override Codes  (Rev. 1757, Issued: 06- 19-09, Effective: 07 -20-09, Implementation: 07- 20-09)  A CWF override code has been developed for A/B MAC (B) or DME MAC use where, in the course of pursuing a reconsideration, a provider or supplier may bring to the attention of the A/B MAC (B) a situation where services on a claim have been denied, but shoul d actually be allowed to be paid through the A/B MAC (B)/DME MAC.  At the A/B MAC (B)/DME MACs discretion, to allow that claim to process through CWF to payment, enter a 2 in the SNF consolidated billing override field.  110.4 - Coding Files and Updates  (Rev. 1757, Issued: 06- 19-09, Effective: 07 -20-09, Implementation: 07- 20-09)  To correspond with the annual and quarterly coding and payment updates, CWF will be provided with files of codes that are not included in consolidated billing and can be paid through the A/B MAC (B) or DME MAC.  These codes are available for informational purposes on the CMS Web site at https://www.cms.gov/Medicare/Medicare -Fee-for-Service- Payment/SNFPPS/ConsolidatedBilling.html.  Changes in designation of codes from excluded to included (or vice versa) in consolidated billing will be considered corrections  to align the codes with policy as opposed to changes in policy.  Newly established Healthcare Common Procedure Coding System codes will be added to CWF edits to allow A/B MACs (B)/DME MACs  to make appropriate payments.   110.4.1 - Annual Update Process  (Rev. 2802, Issued: 10- 25-13, Effective: 01 -01-14, Implementation: 01- 06-14)  Barring any delay in the Medicare Physician Fee Schedule, CMS will provide the new code files 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.   CWF will be provided with 4 coding files (Physician Services, Professional Component of Physician Services to be Submitted with the 26 Modifier, Ambulance, and Therapy) that are effective based on dates of service January 1 through December 31 for that yea r.  New files shall be provided for each calendar year.  Quarterly updates to the four files will continue as usual.  A/B MACs (B)/DME MACs  must continue to respond to rejects and unsolicited responses received from CWF per current methodology.  A/B MACs (B)/DME MACs  must 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 (B)/DME MACs  need not search claims history to identify these claims.  Prior to January 1 of each year, new codes files will be posted to the CMS Web site at.  https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/.  Should this date change, A/B MACs (B)/DME MACs  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 files are posted to the CMS Web site, through their Web sites and list serves, A/B MACs (B)/DME MACs  must notify physician, non-physician practitioners, and suppliers of the availability of the files.   120 - Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)  (Rev. 4409, Issued: 10- 04-19, Effective: 11-05-19, Implementation: 11-05-19)  SNFs billing on Type of Bill (TOB) 21X and rural hospital (non- CAH) swing -bed providers billing on TOB 18X (subject to SNF PPS), will be subject to these requirements. Currently, under the SNF PPS, revenue code 0022 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 Health Insurance Prospective Payment System (HIPPS) Rate Code(s) and assessment periods. The HCPCS/Rates field must contain a 5 -digit HIPPS Code. Under the previous case- mix classification model, the Resource Utilization Groups, version 4 (RUG-IV), the first three positions of the code contained the RUG group, and the last two positions of the code contained a 2- digit assessment indicator (AI) code.  120.1 - HIPPS Updates and Structure Changes  (Rev. 4409, Issued: 10- 04-19, Effective: 11-05-19, Implementation: 11-05-19)  Under PDPM, the HIPPS code is structured differently, as a result of there being five case-mix adjusted rate components under the revised model. The first position represents the Physical and Occupational Therapy case -mix group. The second position represents the Speech -Language Pathology case-mix group. The third character represents the nursing case-mix group. The fourth character represents the Non- Therapy Ancillary (NTA) case -mix group. The fifth character represents the AI code. CMS would note that this also affects the number of potentially valid HIPPS codes under PDPM, as compared to RUG- IV.  The PPS assessment schedule under PDPM is also significantly different from that used under RUG-IV. The only assessments under PDPM that would produce a HIPPS code would be the initial Medicare (5 -day) PPS assessment, which follows the same schedule as u nder the previous RUG-IV model, and the optional Interim Payment Assessment (IPA), which may be completed at any point during a PPS stay.  The initial SNF PDPM HIPPS Codes can be found online at: https://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes.html   Note: AAA00 default will be replaced with ZZZZZ effective October 1, 2019.  120.2 - Interrupted Stay Policy  (Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)  PDPM includes an interrupted stay policy, which would combine multiple SNF stays into a single stay in cases where the patients discharge and readmission occurs within a prescribed window (i.e., interruption window), s imilar to that which exists currently in many other Medicare inpatient facilities.  Specifically, if a patient in a covered Part A SNF stay is discharged from the SNF but returns to the SNF no later than 11:59pm of the third consecutive calendar day after having left Part A coverage, then this would be considered a continuation of the same SNF stay. In such cases, no new patient assessments are required and the variable per diem adjustment is not reset.  If the patient returns to the same SNF outside the interruption window, or returns to a different SNF, then this would be considered a new stay.   The interruption window begins on the first non-covered day following a Part A- covered SNF stay and ends at 11:59pm on the third consecutive non-covered day.  The first non-covered day in this context may be different depending on whether the patient actua lly leaves the facility or simply leaves Part A coverage.  Specifically, if the patient physically leaves the SNF, the first day of the interruption window would be the day of departure itself, whereas if the patient simply discontinues Part A coverage but remains in the SNF, the first day of the interruption window would be the day following the final day of Part A coverage.   Specifying the endpoint of the interruption windows third day as occurring at 11:59 pm rather than at midnight is consistent with the regulations at 42 CFR 411.15(p)(3)(iv), which define a beneficiarys SNF resident status for consolidated billing purposes as ending whenever he or she is formally discharged (or otherwise departs) from the SNF, unless he or she is readmitted (or returns) to that or another SNF . . . before the following midnight (emphasis added). See 10.1 of this chapter, and also see 20.1 in the Medicare Benefit Policy Manual, Chapter 3, which specifies that in counting inpatient days, . . . a day begins at midnight and ends 24 hours later.  However, unlike similar interrupted stay policies under some of the other prospective payment systems, the SNF interrupted stay policy is not used in determining whether bundling would apply to services furnished during the interruption.  That determination would instead continue to follow the longstanding set of rules under 42 CFR 411.15(p)(3) regarding SNF resident status for consolidated billing purposes (see 10ff.).  The day of discharge (as noted above, this date could be different if the patient leaves the facility or simply leaves Part A coverage) is the FROM date and the last day the patient is not in the SNF at midnight is the THROUGH date.  Occurrence span code 74 should be reported for each interruption of more than ONE day.  The interrupted stay would be recorded on the claim in the same manner as is done for the IRF PPS, and as further discussed in the examples below.  Examples: 1) Patient is admitted to SNF on 11/07/19 and is in a covered Part A stay. Patient is discharged from the SNF and admitted to the hospital on 11/20/19.  Patient is readmitted to the same SNF on 11/25/19 and is in a covered Part A stay.  The readmission is a new stay because more than 3 days have passed from the date the patient was discharged from the SNF and the date the patient was readmitted to the same SNF.   New stay  Assessment Schedule: Reset; stay begins with new 5- day assessment.  Variable Per Diem (VPD): Reset: stay begins on Day 1 of VPD Schedule.  2) Patient is admitted to SNF on 11/07/19 and in a covered Part A stay.  The patient is discharged from Part A on 11/20/19 but remains in the facility.  The patient returns to a covered Part A stay on 11/22/19.  This is a continuation of a previous stay because the patient returned to a covered Part A stay within 3 days of being discharged from a covered Part A stay.