(Medicare Claims Processing Manual)

NOTE:   Some HCPCS codes are defined as all professional components in the fee schedule.  Fee schedule definitions apply for this purpose.  Effective July 1, 2001, the Benefits Improvement and Protection Act (BIPA) established payment method II, in which CAHs can bill and be paid for physician services billed to their A/B MAC (A).  CAHs must bill the professional fees using revenue codes 96x, 97x, or 98x on an 85x type of bill (TOB).  Like professional services billed to the A/B MAC (B), the specific line items containing these revenue codes for professional services are excluded from the requirement for consolidated billing.  RHC/FQHC Instructions:    Effective January 1, 2005, section 410 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) amended the SNF consolidated billing law to specify that when a SNFs Part A resident receives the services of a physician (or another type of practitioner that the law identifies as being excluded from SNF consolidated billing) from a RHC or a FQHC, those services are not subject to CB merely by virtue of being furnished under the auspices of the RHC or FQHC.  Accordingly, under section 410 of the MMA, services otherwise included within the scope of RHC and FQHC services that are also described in clause (ii) of section 1888(e)(2)(A) are excluded from consolidated billing, effective with services furnished on or after January 1, 2005.  Only this subset of RHC/FQHC services may be covered and paid separately when furnished to SNF residents during a covered Part A stay (see the regulations at 42 CFR  411.15(p)(2)(xvii) and 405.2411(b)(2)).  Use TOBs 71x and 73x, respectively, to bill for these RHC/FQHC services.  See Pub. 100-02, Medicare Benefit Policy Manual, chapter 13 for additional information on Part B coverage of RHC/FQHC services.   20.1.1.2 - Hospitals Facility Charge in Connection with Clinic Services of a Physician  (Rev. 3230, Issued: 04- 03-15, Effective: 06-15-15, Implementation: 06-15-15)   As noted above in section 20.1.1, physician services are excluded from Part A PPS payment and the requirement for consolidated billing.  When a beneficiary receives clinic services from a hospital -based physician, the physician in this situation would bill his or her own professional services directly to the A/B MAC (B) and would be reimbursed at the facility rate of the Medicare physician fee schedule - which does not include overhead expenses.  The hospital historically has submitted a separate Part B facility charge for the associated overhead expenses to its A/B MAC (A).  The hospitals facility charge does not involve a separate service (such as a diagnostic test) furnished in addition to the physicians professional service; rather, it represents solely the overhead expenses associated with furnishing the professional service itself.  Accordingly, hospitals bill for facility charges under the physician evaluation and management (E&M) codes in the range of 99201-99245 and G0463 (for hospitals paid under the Outpatient Prospective Payment System).   E&M codes, representing the hospitals facility charge for the overhead expenses associated with furnishing the professional service itself, are excluded from SNF CB.  Effective for claims with dates of service on or after January 1, 2006, the CWF will bypass CB edits when billed with revenue code 0510 (clinic visit) with an E&M HCPCS code in the range of 99201- 99245 and, effective January 1, 2014 with HCPCS code G0463.  NOTE:   Unless otherwise excluded in one of the Five Major Categories for billing services to A/B MACs (A) , physician services codes are to be billed to the A/B MAC (B)  by the physician.  Facility charges associated with the physicians clinic visit must be reported as explained above.  20.1.2 - Other Excluded Services Beyond the Scope of a SNF Part A Benefit  (Rev. 4409, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19)  The following services are not included in Part A PPS payment when furnished in a Medicare participating hospital or CAH and may be paid to the provider rendering them.  This exception does not apply if the service is furnished in an ambulatory surgical center  (ASC) or other independent (non- hospital) facility, because it specifically addresses those services that are so far beyond the normal scope of SNF care as to require the intensity of the hospital setting  in order to be furnished safely and effectively.  In transmittals for Part A and B institutional billing providing the annual update list of HCPCS codes affected by SNF consolidated billing, such services are referre d to as  Major Category I of SNF consolidated billing editing.  Note that of the types of services listed, only ambulatory surgeries are listed as inclusions, rather than exclusions, to consolidated billing.   Certain  cardiac catheterizations;    Certain computerized axial tomography (CT) scans;    Certain magnetic resonance imaging (MRIs);    Certain ambulatory surgeries involving the use of a hospital operating room or comparable hospital facilities (i.e., the use of a gastrointestinal (GI) suite or endoscopy suite for the insertion of a percutaneous esophageal gastrostomy (PEG) tube).  For Part A inpatients, the professional portion of these services is billed by the rendering practitioner to the A/B MAC (B).  Any hospital outpatient charges are billed to the A/B MAC (A).    Certain radiation therapies;   Certain angiographies, and lymphatic and venous procedures;    Emergency services; and    Ambulance services when related to an excluded service within this list (see 20.3 for ambulance transportation related to dialysis services).   These relatively costly services are beyond the general scope of care in SNFs, and their receipt has the effect of temporarily suspending a beneficiarys status as a SNF resident for CB purposes with respect to such services.  Even though it may be medic ally appropriate for a beneficiary to be cared for in a SNF while receiving radiation therapy, the SNF is not responsible for paying for excluded radiation therapy itself when the beneficiary receives it as a hospital outpatient.  Similarly, angiography codes and codes for some lymphatic and venous procedures are considered beyond the general scope of services delivered by SNFs.  The hospital or CAH must bill the A/B MAC (A) for the services.  Excluded services provided to Medicare beneficiaries in swing be ds subject to SNF PPS are to be billed on TOB 13x by the swing bed hospital (see 100.1).  Services directly related to these services, defined as services billed for the same place of service and with the same line item date of service as the services listed below, are also excluded from SNF CB, with exceptions as listed below.  This language a ddresses excluding as directly related those items and services that are so closely associated with the excluded procedure that it would actually be impossible to perform the excluded procedure itself without them, such as the anesthesia for an excluded ambulatory surgical procedure under 20.1.2.1, or an otherwise bundled diagnostic test when needed to identify the cause of (and appropriate course of treatment for) a medical emergency under 20.1.2.2.   Note that anesthesia, drugs incident to radiology and supplies will be bypassed by enforcement edits when billed with CT Scans, Cardiac Catheterizations, MRIs, Radiation Therapies, or Angiographies or surgeries.  In general, bypasses also allow CT Scans, Cardiac Catheterization, MRI, Radiation Therapy, Angiography, and Outpatient Surgery HCPCS codes 0001T  0021T, 0024T  0026T, or 10021 -  69990 (except those HCPCS codes listed in Major Category I. F.) to process and pay.  This includes all other revenue code lines on the incoming claim that have the same line item date of service (LIDOS).   20.1.2.1 Outpatient Surgery and Related Procedures - INCLUSION  (Rev. 3612, Issued: 09- 16-16, Effective: 10 -18-16, Implementation: 10- 18-16)  Inclusions, rather than exclusions, are given in this one case, because of the great number of surgical procedures that are excluded and can only be safely performed in a hospital operating room setting.  It is easier to automate edits around the much shorter list of inclusions under this category, representi ng minor procedures (such as debriding a mycotic toenail) that, while technically considered surgery, can nevertheless be safely performed at bedside in the SNF itself.  Additionally, this was the approach originally taken in the regulation to present this information.    Note that anesthesia, drugs, supplies and lab services will be bypassed by enforcement edits when billed with outpatient surgeries excluded  from SNF CB.  The bypass is implemented for these services when the line item date of service matches the line item date of service for the excluded surgery.  For revenue codes not requiring a line item date of service (i.e., pharmacy and supplies), the bypass will be implemented when no line item date of service is present.   See 10.1 above for the link to where transmittals providing current lists of HCPCS codes used for Major Category I SNF consolidated billing editing can be found.  20.1.2.2 - Emergency Services  (Rev. 2573, Issued: 10- 26-12, Effective: 04-01-13, Implementation: 04-01-13)  Emergency room services performed in hospitals, including CAHs, are excluded from SNF CB for beneficiaries that are in skilled Part A SNF stays.  Hospitals report emergency room (ER) services under the 045X (Emergency Room - x represents a varying third digit) revenue code with a line item date of service (LIDOS) indicating the date the patient entered the ER.  Services related to the ER encounter are also excluded from the SNF CB provision.  Emergency services are defined in the regulations at 42 CFR 42 4.101 as . . . services that are necessary to prevent death or serious impairment of health and, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services.  In this context, fal se alarm situations may occasionally arise, in which the initial assessment of a beneficiarys condition as life-threatening subsequently proves to be unfounded (for example, where a patients chest pain and shortness of breath initially appear to be symptoms of a heart attack, but upon subsequent examination turn out to be merely a bad case of indigestion).  Such situations still qualify for the emergency services exclusion from SNF CB as long as the initial symptoms provided a reasonable basis for assuming the onset of a medical emergency, even though this assumption ultimately was not borne out by subsequent events.   Where services related to the ER encounter span more than one service date, hospitals must identify those services by appending a modifier ET (Emergency Services) to those line items.  The reporting of the ET modifier will alert CWF that these are related ER services performed on subsequent dates so the SNF CB edits in CWF will be bypassd.  20.2 - Services Excluded from Part A PPS Payment and the Consolidated Billing Requirement on the Basis of Beneficiary Characteristics and Election  (Rev. 2573, Issued: 10- 26-12, Effective: 04-01-13, Implementation: 04-01-13)  SNF -516  These services must be provided to specific beneficiaries, either: (A) End Stage Renal Disease (ESRD) beneficiaries, or (B) beneficiaries who have elected hospice, by specific licensed Medicare providers, and are excluded from SNF PPS and consolidated billing. SNFs will not be paid for Category II.A services  (dialysis, etc.) when the SNF is the place of service.  To receive Medicare payment, these services must be provided in a renal dialysis facility.  Hospices must also be the only type of provider billing hospice services.   In transmittals for A/B MAC (A) billing that provide the annual update list of HCPCS codes affected by SNF consolidated billing, such services are referred to as Major Category II of SNF consolidated billing editing.  See 10.1 above for the link to wher e transmittals providing current lists of HCPCS codes used for edits for these types of services, known as Major Category II in SNF CB editing for A/B MACs (A).   20.2.1  Dialysis and Dialysis Related Services to a Beneficiary With ESRD (Rev.  4001, Issued: 03- 16-18, Effective: 06 -19-18, Implementation: 06- 19-18)  Beneficiaries with ESRD may receive dialysis and dialysis related services from a hospital -based or free -standing RDF, or may receive home dialysis supplies and equipment from a supplier. The following services are excluded from SNF CB:    Certain dialysis services and supplies, including any related necessary ambulance services;