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April 2005 Part B Medicare Bulletin

Posted April 4, 2005

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2nd Quarter Update - Part B Not Otherwise Classified Drug Fee Schedule

2005 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs

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1st Update to the 2005 Medicare Physician Fee Schedule Database

Note: This article was revised on February 24, 2005, to show the correct CR number in the additional information section. All other information in the article remains the same.

Provider Types Affected
Physicians and providers billing Medicare carriers or Fiscal Intermediaries (FIs) for services paid under the Medicare Physician Fee Schedule

Provider Action Needed
Physicians and providers should be aware of the changes to the Medicare Physician Fee Schedule Database, and identify those changes that impact their practice.

Background
CR 3726 amends payment files issued based upon the November 15, 2004, Final Rules for the 2005 Medicare Physician Fee Schedule Database. Many of the changes relate to a National Coverage Determination (NCD) related to G codes and CPT codes for Positron Emission Tomography (PET), which was effective January 30, 2005.

Additional Information
The changes to the fee schedule involve numerous CPT/HCPCS codes. These changes to the 1st Update to the 2005 Medicare Physician Fee Schedule Database are described in an attachment to CR 3726.

For complete details, please see the official instruction issued to your carrier/FI regarding this change. That instruction may be viewed at: http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

From that Web page, look for CR 3726 in the CR NUM column on the right, and click on the file for that CR.

If you have any questions, please contact your Medicare carrier/FI at their toll-free number, which may be found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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April Quarterly Update to 2005 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement

Note: This article was revised on February 8, 2005, to correct punctuation in the first bullet point on page 3. No other changes were made.

Provider Types Affected
Institutional providers billing claims to Medicare fiscal intermediaries and physicians, practitioners, and suppliers billing Medicare carriers for services

Provider Action Needed

STOP – Impact to You
HCPCS codes are being added to or removed from the SNF consolidated billing enforcement list.

CAUTION – What You Need to Know
Services included on the SNF consolidated billing enforcement list will be paid to SNF Medicare providers only. Services excluded from the SNF consolidated billing enforcement list may be paid to Medicare providers other than SNFs. See Background and Additional Information sections for further explanation.

GO – What You Need to Do
Be aware of the requirements explained below and how they can impact your Medicare payment.

Background
The Centers for Medicare & Medicaid Services (CMS) periodically updates the lists of Healthcare Common Procedure Coding System (HCPCS) codes that are subject to the consolidated billing provision of the SNF Prospective Payment System (SNF PPS).

Quarterly updates now apply to both Fiscal Intermediaries (FIs) and Carriers/Durable Medical Equipment Regional Carriers (DMERCs)
This is the first joint FI/Carrier/DMERCs quarterly update published subsequent to the 2005 Annual Updates. These updates affect claims with dates of service on or after the effective date of the instructions printed below unless otherwise indicated. Services appearing on this HCPCS list (that are submitted on claims to both Medicare FIs and Carriers, including DMERCs), will not be paid by Medicare to providers, other than a SNF, when included in SNF CB.

For the annual notice on SNF CB each January, separate instructions are published for FI and Carriers/DMERCs. The 2005 Annual Update for FIs can be found on the CMS Web site at: http://www.cms.hhs.gov/manuals/pm_trans/R360CP.pdf

Information on the 2005 annual update for Carriers can be found at: http://www.cms.hhs.gov/medlearn/snfcode.asp

Please take note of the following important points:

This notification provides a list of the exclusions, and some inclusions, to SNF CB, and the codes below are being added or removed from the annual update. Note the following:

Major Category I additions noted below means these codes:

Major Category III additions noted below means these services:

Major Category IV additions noted below means these services:

Major Category V additions to therapy inclusions noted below means:

Computerized Axial Tomography (CT) Scans
(Major Category I, FI Annual Update, EXCLUSION)

Note on Codes above:
* Codes replaced HCPCS codes G0131 and G0132. The professional components of these codes were already added with the 2005 annual update as separately payable by the carrier for claims with dates of service on or after January 1, 2005.

Radiation Therapy
(Major Category I, FI Annual Update, EXCLUSION)

Note on Codes above:
^ These codes were discontinued December 31, 2004.
HCPCS code G0256 was discontinued December 31, 2003.
^^ These codes are effective January 1, 2005, and replaced codes C9714 and C9715 and these codes were already added with the 2005 annual update as separately payable by the carrier for claims with dates of service on or after January 1, 2005.

Dialysis Supplies
(Major Category II, FI Annual Update, EXCLUSION)

· Remove A4712 - water, sterile, for injection

Note: HCPCS code A4712 was discontinued December 31, 2003.

Chemotherapy Administration
(Major Category III, FI Annual Update, EXCLUSION)

Note on Codes above:
+ These codes were effective January 1, 2005. These codes were already added with the 2005 annual update as separately payable by the Medicare carrier for claims with dates of service on or after Januray 1, 2005.

Mammography
(Major Category IV, FI Annual Update, EXCLUSIONS)

Diabetic Screening
(Major Category IV, FI Annual Update, EXCLUSIONS)

New Preventive Benefit (Per section 611 of the Medicare Modernization Act (MMA)– Initial Preventive Physical Exam
(Major Category IV, FI Annual Update, EXCLUSIONS)

Note on Code above:

Therapies
(Major Category V, FI Annual Update, INCLUSIONS)

No payment can be made for these codes.

Note: HCPCS code 92525 was discontinued December 31, 2002.

Note: Section 1888 of the Social Security Act codifies SNF PPS and CB. The new coding identified in each update describes the same services that are subject to SNF PPS payment by law. No additional services will be added by these routine updates; that is, new updates are required by changes to the coding system, not because the services subject to SNF CB are being redefined. Other regulatory changes beyond code list updates will be noted when and if they occur.

Implementation
The implementation date for this instruction is April 4, 2005.

Additional Information
For complete details, please see the official instruction issued to your carrier/intermediary regarding this change. That instruction may be viewed at: http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp


From that Web page, look for CR 3683 in the CR NUM column on the right, and click on the file for that CR.

If you have any questions, please contact your carrier/intermediary at their toll-free number, which may be found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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CIGNA Government Services NetCourses Reminder

Sometimes it is hard to fit Medicare training into your busy schedule, so CIGNA Government Services has developed NetCourses. NetCourses are online tutorials and training courses available on demand, any time of the day. Each course contains a pre-test and a post-test so you can evaluate your knowledge of the subject. If you feel you missed something, you can go back and review the information at any time.

The following NetCourses are available at: http://www.cignamedicare.com/Webtraining/Logon.asp, to help meet your Medicare-related training needs.

General Courses

Part B Courses

CIGNA Government Services will continue to launch several NetCourses throughout the year. Be sure to sign-up for our E-Mail Express Notification System (ListServ) at: http://www.cignamedicare.com/medicare_dynamic/mailer/subscribe.asp so you can be notified via e-mail when new tutorials are available.

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Quarterly Update to Correct Coding Initiative (CCI) Edits, Version 11.1, Effective April 1, 2005

Provider Types Affected
Physicians billing Medicare carriers

Provider Action Needed
This is a reminder for physicians to take note of the

quarterly updates to the coding initiatives. The next round of CCI edits will be effective on April 1, 2005. Physicians may view the current CCI edits and the current Mutually Exclusive Code (MEC) edits on the Centers for Medicare & Medicaid Service Web site at: http://www.cms.hhs.gov/physicians/cciedits

The Web site will be updated with the Version 11.1 edits as soon as they are effective.

Background
The National Correct Coding Initiative developed by CMS helps promote national correct coding methodologies and controls improper coding. The coding policies developed are based on coding conventions defined in the American Medical Association’s Current Procedural Terminology (CPT) manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practice, and review of current coding practice.

The latest package of CCI edits, Version 11.1, is effective on April 1, 2005. This version will include all previous versions and updates from January 1, 1996 to the present and will be organized in two tables: Column 1/Column 2 Correct Coding Edits and MEC Edits.

Additional Information
The CCI and MEC files will be maintained in the Internet Only Manual, Chapter 23, Section 20.9, which can be found at: http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp

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Implementation of the Abstract File for Purchased Diagnostic Tests/Interpretations (Supplemental to CR 3481)

Provider Types Affected
Physicians and Independent Diagnostic Testing Facilities (IDTFs) billing Medicare carriers for purchased diagnostic tests/interpretations

Provider Action Needed

STOP
Related CR 3694 replaces the requirement in CR 3481 instructing carriers to pay physicians for diagnostic tests and interpretations performed outside of the local carrier’s jurisdiction.

CAUTION
All other instructions in CR3481 remain in effect.

GO – What You Need to Do
Medicare carriers will continue to pay physicians at the local rate, until further notice, for services purchased outside of the carrier’s jurisdiction when submitted by a physician enrolled in the carrier’s jurisdiction. Physicians should continue to report their name and service facility location on claims for purchased tests/interpretations performed outside of the local carrier’s jurisdiction.

Physicians use their own PIN to bill for both the purchased portion of the test and the portion of the test that they performed. Suppliers (laboratories and IDTFs) are to bill local carriers regardless of where the tests are performed and carriers are to pay suppliers based on ZIP codes.

NOTE: Physicians should continue to follow the billing instructions provided in Change Request 3630 (Transmittal 415, issued on December 23, 2004) until further notice.

Background
CR 3481 instituted a national abstract file of the Medicare Physician Fee Schedule (MPFS) containing Healthcare Common Procedure Coding System (HCPCS) codes billable as purchased diagnostic tests and interpretations for every locality throughout the country. Effective April 1, 2005, suppliers, including laboratories, physicians, and IDTFs, are to bill their local carrier for purchased diagnostics tests and interpretations, regardless of the location where the service was furnished. However, until further notice, CMS is delaying the implementation of the billing instructions specified in CR 3481 for purchased diagnostic service claims submitted by physicians due to a locality reporting issue.

Effective April 1, 2005, carriers should price claims based on the ZIP code of the location where the service was rendered when submitted by a laboratory or IDTF, using a CMS-supplied abstract file of the MPFS containing the HCPCS codes that are payable under the MPFS as either a purchased test or interpretation for the calendar year. Until further notice, carriers should pay the local rate for purchased interpretation claims when submitted by a physician.

Carriers should accept and process claims when billed by suppliers enrolled in the carrier’s jurisdiction, regardless of the location where the service was furnished. Carriers should allow claims submitted by an IDTF if the IDTF has previously enrolled to bill for purchased diagnostic test components it performs

Implementation
The implementation date for this instruction is April 4, 2005.

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Coordination of Benefits Agreement (COBA) Detailed Error Report Notification Process

Provider Types Affected
All physicians, providers, and suppliers billing Medicare Fiscal Intermediaries (FIs) and carriers

Provider Action Needed
This instruction includes information contained in Change Request (CR) 3709 which directs Medicare Contractors (carriers, intermediaries, and Durable Medical Equipment Regional Carriers [DMERCs]) to issue special automated correspondence from their internal systems to physicians, providers, and suppliers informing them that claims that were expected to be crossed over to supplemental payers/insurers (as indicated on a previous Remittance Advice) were not crossed.

Background
Through the national COBA process, Medicare will automatically cross claims over to a supplemental payer/insurer that may pay after Medicare has made its payment decision on the claim. There may be situations (such as claim errors related to HIPPA) that prevent Medicare from crossing a claim over to the supplemental payer/insurer.

In those situations where Medicare is unable to cross the claim, CR 3709 directs Medicare Contractors to issue special automated correspondence to notify physicians, suppliers, and providers when claims previously selected for crossover by Medicare were subsequently unable to be crossed to the supplemental payer/insurer.

The correspondence sent to the physician, supplier, or provider will contain specific claim information, including the Internal Control Number (ICN)/Document Control Number (DCN), Health Insurance Claim (HIC) number, Medical Record Number (if the letter is from an intermediary and the claim was for Part A services), Patient Control Number (if present on the claim), beneficiary name, date of service, and the date the claim was processed. In addition, the letter will include the following message:

“The above claim(s) was/were not crossed over to the patient’s supplemental insurer due to claim data errors.”

Upon receipt of such correspondence, the physician, supplier, or provider is advised that the claim is not being crossed automatically and the provider may take appropriate action to obtain payment from the supplemental payer/insurer.

Implementation
The implementation date for CR 3709 is July 5, 2005.

Additional Information
Complete details of the COBA Error Notification process are included in the official instruction issued to your carrier/DMERC/intermediary. That instruction may be viewed at: http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

From that Web page, look for CR 3709 in the CR NUM column on the right, and click on the file for that CR.

If you have any questions, please contact your carrier/DMERC/intermediary at their toll-free number, which may be found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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Infusion Pumps: C-Peptide Levels as a Criterion for Use

Provider Types Affected
Physicians, suppliers, and providers providing continuous subcutaneous insulin infusion and related drugs/supplies in the treatment of diabetic patients in the home setting and billing Medicare carriers or Fiscal Intermediaries (FIs)

Provider Action Needed

STOP – Impact to You
This article and related CR 3705 adds beta cell autoantibody testing as an alternative diagnostic per the updated C-peptide testing requirement for the use of insulin infusion pumps, effective for services performed on or after December 17, 2004.

CAUTION – What You Need to Know
Providers/suppliers treating Medicare diabetic patients with infusion pumps should be aware of this new Medicare coverage policy.

GO – What You Need to Do
Ensure that your staff is aware of this new coverage and that they bill according to the information in this article.

Background
On August 26, 1999, the Centers for Medicare & Medicaid Services (CMS) issued the first decision memorandum (DM) for continuous subcutaneous insulin infusion pumps (CSII) that utilized a C-peptide testing requirement for Medicare coverage of CSII pump therapy. On May 11, 2001, CMS issued a second DM for insulin pump: “C-Peptide Levels as a Criterion for Use,” and on January 1, 2002, CMS revised the laboratory value for the C-peptide testing requirement for Medicare coverage of CSII pump therapy.

Effective for services performed on or after December 17, 2004, in addition to meeting criterion A or B, the beneficiary with diabetes must be insulinopenic per the fasting C-peptide testing requirement or, as an alternative must be beta cell autoantibody positive. Insulinopenia is defined as a fasting C-peptide level that is less than or equal to 110% of the lower limit of normal of the laboratory’s measurement method. For patients with renal insufficiency and a creatinine clearance (actual or calculated from age, gender, weight, and serum creatinine) < 50 ml/minute, insulinopenia is defined as a fasting C-peptide level that is less than or equal to 200% of the lower limit of normal of the laboratory’s measurement method. CMS establishes that fasting C-peptide levels will only be considered valid when a concurrently obtained fasting glucose is < 225 mg/dL.

Levels need only be documented once in the patient’s medical records.

Coverage of all other uses of CSII that adheres with the Category B IDE clinical trials regulation (42 CFR 405.201) or routine cost under the clinical trials policy (Medicare NCD Manual Chapter 1, Part 4, Section 310.1) will continue.

Those billing for these services should note that Medicare carriers will accept, effective for services on or after December 17, 2004, CPT code 84681 (C-peptide) or CPT code 86337 (insulin antibodies) when diagnosis codes 250.00-259.93 are also reported on a claim.

Additional Information
The official instruction issued to your Medicare carrier/intermediary regarding this change may be found by going to: http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

From that Web page, look for CR 3705 in the CR NUM column on the right, and click on the file for that CR.

If you have questions regarding this issue, contact your carrier/intermediary on their toll free number, which is available at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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Quarterly Provider Update

The Quarterly Provider Update is a comprehensive resource published by the Centers for Medicare & Medicaid Services (CMS) on the first business day of each quarter. It is a listing of all non-regulatory changes to Medicare including Program Memoranda, manual changes, and any other instructions that could affect providers. Regulations and instructions published in the previous quarter are also included in the Update. The purpose of the Quarterly Provider Update is to:

To receive notification when regulations and program instructions are added throughout the quarter, sign up for the Quarterly Provider Update listserv (electronic mailing list) at: http://list.nih.gov/cgi-bin/wa?SUBED1=cms-qpu&A=1.

The Quarterly Provider Update can be accessed at http://www.cms.gov/providerupdate. We encourage you to bookmark this Web site and visit it often for this valuable information.

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Medicare Prescription Drug, Improvement, and Modernization Act (MMA) – Skilled Nursing Facility Consolidated Billing and Services of Rural Health Clinics and Federally Qualified Health Centers

NOTE: This article was revised on February 18, 2005. Specifically, line 4 of the “Clarification” statement below was modified to say “These “excluded” services….” instead of “These included services…” We regret this error.

Provider Types Affected
Skilled Nursing Facilities (SNFs), physicians, Rural Health Clinics (RHCs), and Federally Qualified Health Centers (FQHCs).

Provider Action Needed
This Special Edition is an informational article that describes SNF Consolidated Billing (CB) as it applies to services provided by RHCs and FQHCs.

Clarification: The SNF CB requirement makes the SNF itself responsible for including on the Part A bill that it submits to its Medicare intermediary almost all of the services that a resident receives during the course of a Medicare-covered stay, except for a small number of services that are specifically excluded from this provision. These “excluded” services can be separately furnished to the resident and billed under Medicare Part B by a variety of outside sources. These sources can include other providers of service (such as hospitals), which would submit the bill for Part B services to their Medicare intermediary, as well as practitioners and suppliers who would generally submit their bills to a Medicare Part B carrier. Bills for certain types of items or equipment would be submitted by the supplier to their Medicare Durable Medical Equipment Regional Carrier (DMERC.)

Background
When the SNF Prospective Payment System (PPS) was introduced in 1998, it changed not only the way SNFs are paid, but also the way SNFs must work with suppliers, physicians, and other practitioners. CB places with the SNF itself the Medicare billing responsibility for virtually all of the services that the SNF’s residents receive during the course of a covered Part A stay.

Payment for this full range of services is included in the SNF PPS global per diem rate. The only exceptions are those services that are specifically excluded from this provision, which remain separately billable to Medicare Part B by the entity that actually furnished the service. For a detailed overview of SNF CB and a list of the services excluded from SNF CB, see Medlearn Matters Special Edition SE0431 at:
http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0431.pdf

Prior to January 1, 2005, RHC and FQHC services did not appear on the original list of services that were statutorily excluded from the SNF CB requirement. Consequently, when a SNF resident receives RHC or FQHC services during a covered Part A stay, the services were bundled into the SNF’s comprehensive per diem payment for the covered stay itself, and were not separately billable as RHC or FQHC services to the Fiscal Intermediary (FI). This means that rather than submitting a separate bill to the FI for these services, the RHC or FQHC looked to the SNF for its payment.

However, Section 410 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA, P.L. 108-173) amended the law to specify that when a SNF’s 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 an RHC or FQHC, those services are not subject to CB merely by virtue of being furnished under the auspices of the RHC or FQHC.

In effect, the amendment enables such RHC and FQHC services to retain their separate identity as excluded “practitioner” services. As such, these RHC and FQHC services remain separately billable to the FI when furnished to an SNF resident during a covered Part A stay. The MMA specifies that this provision became effective with services furnished on or after January 1, 2005.

Additional Information
See Medlearn Matters Special Edition SE0431 for a detailed overview of SNF CB. This article lists services excluded from SNF CB and can be found at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0431.pdf

Also, the Centers for Medicare & Medicaid Services (CMS) Medlearn Consolidated Billing Web site can be found at: http://www.cms.hhs.gov/medlearn/snfcode.asp

It includes the following relevant information:

The SNF PPS Consolidated Billing Web site can be found at: http://www.cms.hhs.gov/providers/snfpps/cb

It includes the following relevant information:

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Modified Edits for Matching Claims Data to Beneficiary Records

Provider Types Affected
All Medicare physicians, providers, and suppliers

Provider Action Needed

STOP – Impact to You
Claims submitted to Medicare must match a Medicare beneficiary record on Health Insurance Claim Number, beneficiary’s last name (surname), and the beneficiary’s first name.

CAUTION – What You Need to Know
The name reported on the claim should always be the name shown on the beneficiary’s Medicare card. If the name submitted does not match the name on Medicare’s files for that beneficiary claim number, Medicare will deny the claim.

GO – What You Need to Do
Be aware of this issue and advise your billing staff they should always use the name from the Medicare card when submitting the claim, even if the patient indicates the name on the Medicare card is incorrect.

Background
Over the past several months, the Centers for Medicare & Medicaid Services (CMS) reviewed its personal characteristics editing logic for processing Medicare claims. The review identified a weakness where processed claims were approved for payment under the wrong beneficiary account number. One of Medicare’s key claims processing systems, known as the Common Working File (CWF), was approving claims where the beneficiary name and Health Insurance Claim Number did not match the name and number on the Medicare card.

The Office of the Inspector General in the Department of Health and Human Services recommended that CMS implement a modified process for matching the claim information to the beneficiary information on CWF files to eliminate erroneous payments caused by the existing matching criteria.

In October 2004, CMS made a software change to require an exact match on beneficiary First Initial, Surname, and Health Insurance Claim Number submitted on the claim. Since this change was implemented the number of denials because of name/number mismatch tripled.
To resolve these claim denials, providers should bill using the name and number as it appears on the beneficiary Medicare card. If the beneficiary insists the Medicare card is incorrect, advise the beneficiary to contact their local servicing Social Security Field Office to obtain a new Medicare card.

If you have any questions regarding this issue, contact your Medicare carrier, intermediary, or durable medical equipment regional carrier at their toll free number. You can find that number on the Web at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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Online Medicare Participating Physicians and Suppliers Directory (MEDPARD)

In an ongoing effort to provide Medicare beneficiaries with information to assist them in making health care choices, the Centers for Medicare & Medicaid Services has a Participating Physicians and Suppliers Directory. The directory contains the names, addresses, office phone numbers, and specialties of Medicare participating physicians, practitioners and suppliers who have agreed to accept assignment on all Medicare covered services. In addition, the directory contains information about the physician’s medical school attended, year of graduation, any board certifications in a medical specialty, gender, and hospitals at which the physician has admitting privileges. The directory is updated monthly and includes any foreign language capabilities of the physician.

The directory can be found on the Centers for Medicare & Medicaid Services beneficiary Web site, which is located on the home page under the Participating Physician Directory at: www.medicare.gov. The directory is available at no cost to the public.

The information in the directory database comes from the Unique Physician Identification Number (UPIN) Registry. The UPIN Registry is updated monthly. Corrections or changes to the information will be reflected on the Web site, the month after an update is made to the UPIN Registry.

In the future, the directory will contain information on whether a physician is accepting new Medicare patients. The Participating Physicians/Supplier Directory for physicians, practitioners, and suppliers located in the States of Idaho, North Carolina, and Tennessee can also be found on the CIGNA Government Services Part B Web site at: www.cignamedicare.com/medicare_dynamic/medpard/index.html.

Any questions regarding the MEDPARD should be addressed to CIGNA Government Services’s Customer Service Units:

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MMA- Revisions to Payment for Services Provided Under a Contractual Arrangement

Provider Types Affected
Physicians, providers, and suppliers billing Medicare carriers provided under a contractual arrangement

Provider Action Needed
This article includes information provided in Change Request (CR) 3628 which makes a slight revision to the language in the Centers for Medicare & Medicaid Services (CMS) Manual System on payment for services provided under a contractual arrangement.

Background
The Medicare Claims Processing Manual (Pub. 100-04, Chapter 1 (General Billing Requirements), Section 30.2.7 (Payment for services provided under a contractual arrangement)) has been revised as a result of the language published in the November 15, 2004, Physician Fee Schedule final rule (CMS-1429F) concerning section 952 of the Medicare Modernization Act (MMA). Instead of stating that the contractual arrangement between an entity and the other physician or provider should include pertinent Medicare program integrity safeguards, CMS is now stating that the entity and the physician or other person are subject to those program integrity safeguards per the following:

The entity billing and receiving payment and the person reassigning his or her billing and payment rights are both responsible for compliance with the Medicare program integrity safeguards beginning on January 1, 2005, (the effective date of CMS-1429-F).

Also, a Medicare carrier may make payment to an entity (i.e., a person, group, or facility enrolled in the Medicare program) that submits a claim for services provided by a physician or other person under a contractual arrangement with that entity, regardless of where the service is furnished. Thus, the service may be furnished on or off the premises of the entity submitting the bill and receiving payment (excluding billing agents).

Implementation
The implementation date for this instruction is March 15, 2005.

Additional Information
For complete details, please see the official instruction issued to your carrier/intermediary regarding this change. That instruction may be viewed at: http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

From that Web page, look for CR 3628 in the CR NUM column on the right, and click on the file for that CR.

If you have any questions, please contact your carrier/intermediary at their toll-free number, which may be found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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Routine Foot Care

Medicare will not cover routine foot care unless a patient has a systemic condition (e.g., metabolic, neurologic, or peripheral vascular disease) that requires scrupulous professional foot care due to: 1) a severe circulatory embarrassment; or 2) areas of diminished sensation in the individual’s legs or feet.


Medicare defines routine foot care as:

Coverage Conditions
Some of the underlying conditions that might justify coverage of routine foot care include diabetes, arteriosclerosis, peripheral neuropathies, and chronic thrombophlebitis. To qualify for routine foot care, the patient must be under the active care of a doctor of medicine or osteopathy who documents the condition. Claims for this type of foot care will not be paid in the absence of convincing evidence that nonprofessional performance of the service would have been hazardous for the beneficiary because of the stated underlying systemic condition.

The mere statement of a diagnosis such as diabetes does not in itself indicate the severity of the condition nor does it completely document the need for a physician’s level of care. Class findings are needed.

NOTE: Routine foot care may be covered only when it may pose a health hazard when performed by a nonprofessional person.

Claim Submission

Procedure Codes
Services for routine foot care should be billed using the following procedure codes:

11055 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion. Report number of service “one”*
11056 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); two to four lesions. Report number of service “one”*
11057 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); more than four lesions. Report number of service “one”*
11719 Trimming of nondystrophic nails; any number. (Report number of service “one” regardless of the number of nails you are trimming).
G0127 Trimming of dystrophic nails, any number. (Report number of service “one” regardless of the number of nails you are trimming).

*The number of lesions reported should reflect the total for both feet.

Coverage Requirements
Claims for routine foot care must include the following information in order to be considered for coverage:

Systemic Conditions
Although not intended as a comprehensive list, the CMS Manual System, Pub 100-2, Medicare Benefit Policy, Chapter 15, Section 290
(http://www.cms.hhs.gov/manuals/102_policy/bp102c15.pdf) lists the following metabolic, neurologic, and peripheral vascular diseases (with synonyms in parentheses) that most commonly represent the underlying conditions that might justify coverage for routine foot care.

When the patient's condition is one of those designated by an asterisk (*), routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition.

Non-Covered Diagnoses
The following diagnoses and conditons do not meet criteria for coverage of routine foot care:

Class Findings
Class findings may be reported through the use of modifiers in both electronic and paper claim submissions.

These modifiers are:

The class A, B, and C findings refer to certain categories of physical and/or clinical findings that are consistent with the diagnosis given and indicative of severe peripheral involvement. A detailed class-by-class listing of these physical or clinical findings appears below.

Class A

Class B

Class C

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Skilled Nursing Facility Consolidated Billing

NOTE: This article was revised on February 18, 2005. Specifically, line 4 of the “Clarification” statement below was modified to say “These “excluded” services….” instead of “These included services…” We regret this error.

Provider Types Affected
All Medicare providers, suppliers, physicians, skilled nursing facilities (SNFs), and rural swing bed hospitals

Provider Action Needed
This article is informational only and is intended to remind affected providers that SNFs must submit all Medicare claims for the services its residents receive, except for a short list of specifically excluded services as mentioned in the “Excluded Services” below. This requirement was established initially as specified in the Balanced Budget Act of 1997 (BBA, P.L. 105-33) and is known as SNF Consolidated Billing (CB).

Clarification: The SNF CB requirement makes the SNF itself responsible for including on the Part A bill that it submits to its Medicare intermediary almost all of the services that a resident receives during the course of a Medicare-covered stay, except for a small number of services that are specifically excluded from this provision. These “excluded” services can be separately furnished to the resident and billed under Medicare Part B by a variety of outside sources. These sources can include other providers of service (such as hospitals), which would submit the bill for Part B services to their Medicare intermediary, as well as practitioners and suppliers who would generally submit their bills to a Medicare Part B carrier. (Bills for certain types of items or equipment would be submitted by the supplier to their Medicare durable medical equipment regional carrier (DMERC.)

Background
Prior to the Balanced Budget Act of 1997 (BBA), a SNF could elect to furnish services to a resident in a covered Part A stay, either:

In each of these circumstances, the SNF billed the Medicare Part A intermediary for the services. However, the SNF also had the further option of “unbundling” a service altogether; that is, the SNF could permit an outside supplier to furnish the service directly to the resident, and the outside supplier would submit a bill to its Medicare Part B carrier (or DMERC), without any involvement of the SNF itself. This practice created several problems, including the following:

Based on the above-mentioned problems, Congress enacted the Balanced Budget Act of 1997 (BBA), Public Law 105-33, Section 4432(b), and it contains a CB requirement for SNFs. Under the CB requirement, an SNF itself must submit all Medicare claims for the services that its residents receive (except for specifically excluded services listed below).

Conceptually, SNF CB resembles the bundling requirement for inpatient hospital services that’s been in effect since the early 1980s-assigning to the facility itself the Medicare billing responsibility for virtually the entire package of services that a facility resident receives, except for certain services that are specifically excluded.

CB eliminates the potential for duplicative billings for the same service to the Part A fiscal intermediary by the SNF and the Part B carrier by an outside supplier. It also enhances the SNF’s capacity to meet its existing responsibility to oversee and coordinate the total package of care that each of its residents receives.

Effective Dates
CB took effect as each SNF transitioned to the Prospective Payment System (PPS) at the start of the SNF’s first cost reporting period that began on or after July 1, 1998.

The original CB legislation in the BBA applied this provision for services furnished to every resident of an SNF, regardless of whether Part A covered the resident’s stay. However, due to systems modification delays that arose in connection with achieving Year 2000 (Y2K) compliance, the Centers for Medicare & Medicaid Services (CMS) initially postponed implementing the Part B aspect of CB, i.e., its application to services furnished during noncovered SNF stays.

The aspect of CB related to services furnished during noncovered SNF stays has now essentially been repealed altogether by Section 313 of the Benefits Improvement and Protection Act of 2000 (BIPA, P.L. 106-554, Appendix F). Thus, with the exception of physical therapy, occupational therapy, and speechlanguage pathology services (which remain subject to CB regardless of whether the resident who receives them is in a covered Part A stay) this provision now applies only to those services that an SNF resident receives during the course of a covered Part A stay.

Excluded Services
There are a number of services that are excluded from SNF CB. These services are outside the PPS bundle, and they remain separately billable to Part B when furnished to an SNF resident by an outside supplier. However, Section 4432(b)(4) of the BBA (as amended by Section 313 (b)(2) of the BIPA) requires that bills for these particular excluded services, when furnished to SNF residents, must contain the SNF’s Medicare provider number. Services that are categorically excluded from SNF CB are the following:

Physician “Incident To” Services
While CB excludes the types of services described above and applies to the professional services that the practitioner performs personally, the exclusion does not apply to physician “incident to” services furnished by someone else as an “incident to” the practitioner’s professional service. These “incident to” services furnished by others to SNF residents are subject to CB and, accordingly, must be billed to Medicare by the SNF itself.

In Program Memorandum (PM) Transmittal # A-98-37 (November 1998, reissued as PM transmittal # A-00-01, January 2000), CMS identified specific types of outpatient hospital services that are so exceptionally intensive or costly that they fall well outside the typical scope of SNF care plans. CMS has excluded these services from SNF CB as well (along with those medically necessary ambulance services that are furnished in conjunction with them). These excluded service categories include:

Effective with services furnished on or after April 1, 2000, the Balanced Budget Refinement Act of 1999 (BBRA, P.L. 106-113, Appendix F) has identified certain additional exclusions from CB. The additional exclusions enacted in the BBRA apply only to certain specified, individual services within a number of broader service categories that otherwise remain subject to CB. Within the affected service categories the exclusion applies only to those individual services that are specifically identified by HCPCS code in the legislation itself, while all other services within those categories remain subject to CB. These service categories are:

• Chemotherapy items and their administration;
• Radioisotope services; and
• Customized prosthetic devices.

In addition, effective April 1, 2000, this section of the BBRA has unbundled those ambulance services that are necessary to transport an SNF resident offsite to receive Part B dialysis services.

Finally, effective January 1, 2004, as provided in the August 4, 2003, final rule (68 Federal Register 46060), two radiopharmaceuticals, Zevalin and Bexxar, were added to the list of chemotherapy drugs that are excluded from CB (and, thus, are separately billable to Part B when furnished to a SNF resident during a covered Part A stay).


Effects of CB
SNFs can no longer “unbundle” services that are subject to CB to an outside supplier that can then submit a separate bill directly to the Part B carrier. Instead, the SNF itself must furnish the services, either directly, or under an “arrangement” with an outside supplier in which the SNF itself (rather than the supplier) bills Medicare. The outside supplier must look to the SNF (rather than to Medicare Part B) for payment.

In addition, SNF CB:

Additional Information
While this article presents an overview of the SNF CB process, CMS also has a number of articles that provide more specifics on how SNF CB applies to certain services and/or providers. These articles are as follows:

In addition, the CMS SNF Consolidated Billing Web site can be found at: http://www.cms.hhs.gov/medlearn/snfcode.asp

It includes the following relevant information:

The SNF PPS Consolidated Billing Web site can be found at: http://www.cms.hhs.gov/providers/snfpps/cb
It included the following relevant information:

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Skilled Nursing Facility Consolidated Billing and Erythropoietin (EPO, Epoetin Alfa) and Darbepoetin Alfa (Aranesp)

Note: This article was revised on January 25, 2005, to include clarifying language, but no substantive changes were made.

Provider Types Affected
Skilled Nursing Facilities (SNF), physicians, suppliers, end-stage renal disease (ESRD) facilities, and hospitals

Provider Action Needed
This Special Edition is informational only and describes SNF Consolidated Billing (CB) as it applies to Erythropoietin (EPO, Epoetin Alfa) and Darbepoetin Alfa (Aranesp) and related services.

Clarification: The SNF CB requirement makes the SNF itself responsible for including on the Part A bill that it submits to its Medicare intermediary, almost all of the services that a resident receives during the course of a Medicare covered stay, except for a small number of services that are specifically excluded from this provision. These excluded services can be separately furnished to the resident and billed under Medicare Part B by a variety of outside sources. These sources can include other providers of services (such as hospitals), which would submit the bill for Part B services to their Medicare intermediary, as well as practitioners and suppliers who would generally submit their bills to a Medicare Part B carrier. (Bills for certain types of items or equipment would be submitted by the supplier to their Medicare Durable Medical Equipment Regional Carrier (DMERC)).

Background
The original Balanced Budget Act of 1997 list of exclusions from the PPS and CB for SNF Part A residents specified the services described in section 1861(s)(2)(O) of the Social Security Act-the Part B erythropoietin (EPO) benefit. This benefit covers EPO and items related to its administration for those dialysis patients who can self-administer the drug, subject to methods and standards established by the Secretary for its safe and effective use (see 42 CFR 405.2163(g) and (h)). See Medlearn Matters Special Edition SE0431 for a detailed overview of SNF CB, including a section on services excluded from SNF CB.

This article can be found at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0431.pdf

Regulations at 42 CFR 414.335 describe payment for EPO and require that EPO be furnished by either a Medicare approved End Stage Renal Disease (ESRD) facility or a supplier of home dialysis equipment and supplies. The amount that Medicare pays is established by law. Thus, the law and implementing regulations permit a SNF to unbundle the cost of the Epogen drug when it is furnished by an ESRD facility or an outside supplier, which can then bill their carrier/intermediary for it.

An SNF that elects to furnish EPO to its Part A resident itself cannot be separately reimbursed over and above the Part A SNF PPS per diem payment amount for the Epogen drug. As explained above, the exclusion of EPO from CB and the SNF PPS applies only to those services that meet the requirements for coverage under the separate Part B EPO benefit, i.e., those services that are furnished and billed by an approved ESRD facility or an outside dialysis supplier.

By contrast, if the SNF itself elects to furnish EPO services (including furnishing the Epogen drug) to a resident during a covered Part A stay (either directly with its own resources, or under an “arrangement” with an outside supplier in which the SNF itself does the billing), the services are no longer considered Part B EPO services, but rather, become Part A SNF services. Accordingly, they would no longer qualify for the exclusion of Part B EPO services from CB, and would instead be bundled into the PPS per diem payment that the SNF receives for its Part A services.

Note: The Part B coverage rules that apply to EPO are applied in the same manner to Aranesp. (See Medicare Claims Processing Manual, Pub.100-04, Chapter 8 – Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, §60.7.2; see also Medicare Benefit Policy Manual, Pub. 100-02, Chapter 11 – End Stage Renal Disease (ESRD), §90). Accordingly, Aranesp is now excluded on the same basis as EPO.

Note: EPO (Epoetin Alfa, trade name Epogen)/DPA (Darbepoetin Alfa, trade name Aranesp) are not separately billable when provided as treatment for any illness other than ESRD. In this case, the SNF is responsible for reimbursing the supplier. The SNF should include the charges on the Part A bill filed with its intermediary for that beneficiary.


Additional Information
Medlearn Matters SE0431, containing the list of services excluded from SNF CB, can be found at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0431.pdf

The Medicare Renal Dialysis Facility Manual, Chapter II, Coverage of Services can be found at the following CMS Web site: http://www.cms.hhs.gov/manuals/29_rdf/rd200.asp?#_1_17

Also, you can find the Medicare Benefit Policy Manual Chapter 11 and Chapter 17 regarding billing and payment details for EPO and DPA at the following CMS Web site:

http://www.cms.gov/manuals/102_policy/bp102c11.pdf and: http://www.cms.gov/manuals/102_policy/bp102c17.pdf

The CMS Consolidated Billing Web site can be found at: http://www.cms.hhs.gov/medlearn/snfcode.asp

It includes the following relevant information:

The CMS Skilled Nursing Facility Prospective Payment System (SNF PPS) Web site can be found at:
http://www.cms.hhs.gov/providers/snfpps/cb

It includes the following relevant information:

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Skilled Nursing Facility Consolidated Billing and Preventive/Screening Services

NOTE: This article was revised on February 18, 2005. Specifically, line 4 of the “Clarification” statement below was modified to say “These “excluded” services….” instead of “These included services…” We regret this error.

Provider Types Affected
Skilled Nursing Facilities (SNFs), physicians, suppliers, and providers

Provider Action Needed
This Special Edition is an informational article that describes SNF Consolidated Billing (CB) as it applies to preventive and screening services provided to SNF residents.

Clarification: The SNF CB requirement makes the SNF itself responsible for including on the Part A bill that it submits to its Medicare intermediary almost all of the services that a resident receives during the course of a Medicare-covered stay, except for a small number of services that are specifically excluded from this provision. These “excluded” services can be separately furnished to the resident and billed under Medicare Part B by a variety of outside sources. These sources can include other providers of service (such as hospitals), which would submit the bill for Part B services to their Medicare intermediary, as well as practitioners and suppliers who would generally submit their bills to a Medicare Part B carrier. (Bills for certain types of items or equipment would be submitted by the supplier to their Medicare durable medical equipment regional carrier (DMERC)).

Background
When the Skilled Nursing Facility (SNF) prospective payment system (PPS) was introduced in the Balanced Budget Act of 1997 (BBA, P.L. 105-33, Section 4432), it changed the way SNFs are paid, and the way SNFs must work with suppliers, physicians, and other practitioners. CB assigns to the SNF itself the Medicare billing responsibility for virtually all of the services that the SNF’s residents receive during the course of a covered Part A stay. See Medlearn Matters article SE0431 for a detailed overview of SNF CB, including a section on services excluded from SNF CB. This article can be found at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0431.pdf


The BBA identified a list of services that are excluded from SNF CB. These services are primarily those provided by physicians and certain other types of medical practitioners, and they can be separately billed to Medicare Part B carriers directly by the outside entity that furnishes them to the SNF’s resident (Social Security Act, Section 1888(e)(2)(A)(ii)). Since the BBA did not list preventive and screening services among the services identified for exclusion, these services are included within the scope of the CB provision.

However, reimbursement for covered preventive and screening services, such as vaccines and mammographies, is subject to special billing procedures. As discussed in the May 12, 1998, Federal Register (63 FR 26296), since preventive services (such as vaccinations) and screening services (such as screening mammographies) do not appear on the exclusion list, they are subject to CB. Accordingly, if an SNF resident receives, for example, a flu vaccine during a covered Part A stay, the SNF itself is responsible for billing Medicare for the vaccine, even if it is furnished to the resident by an outside entity.

Nevertheless, even though the CB requirement makes the SNF itself responsible for billing Medicare for a preventive or screening service furnished to its Part A resident, the SNF would not include the service on its Part A bill, but would instead submit a separate bill for the service. This is because the Part A SNF benefit is limited to coverage of “diagnostic or therapeutic” services (i.e., services that are reasonable and necessary to diagnose or treat a condition that has already manifested itself). (See Sections 1861(h) following (7), 1861(b)(3), and 1862(a)(1) of the Social Security Act.) Accordingly, the Part A SNF benefit does not encompass screening services (which serve to detect the presence of a condition while it is still in an early, asymptomatic stage) or preventive services (which serve to ward off the occurrence of a condition altogether). Such services are always covered under Part B, even when furnished to a beneficiary during the course of a covered Part A SNF stay. Under Section 1888(e)(9) of the Social Security Act, payment for an SNF’s Part B services is made in accordance with the applicable fee schedule for the type of service being billed.

Additional Information
See Medlearn Matters Special Edition SE0431 for a detailed overview of SNF CB. This article lists services excluded from SNF CB and can be found at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0431.pdf

The Centers for Medicare & Medicaid Services (CMS) Medlearn Consolidated Billing Web site is at:
http://www.cms.hhs.gov/medlearn/snfcode.asp

It includes the following relevant information:

The SNF PPS Consolidated Billing Web site can be found at: http://www.cms.hhs.gov/providers/snfpps/cb

It includes the following relevant information:

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Skilled Nursing Facility Consolidated Billing as It Relates to Certain Diagnostic Tests

NOTE: This article was revised on February 18, 2005. Specifically, line 4 of the “Clarification” statement below was modified to say “These “excluded” services….” instead of “These included services…” We regret this error.

Provider Types Affected
Skilled Nursing Facilities (SNFs), physicians, suppliers, providers, and radiology centers

Provider Action Needed
This Special Edition is an informational article that describes SNF Consolidated Billing (CB) as it applies to certain diagnostic tests that include both a technical component (representing the test itself) and a professional component (representing the physician’s interpretation of the test). These tests commonly include diagnostic radiology procedures (such as x-rays) and laboratory tests, but can also include other types of diagnostic procedures (such as audiology services) as well.

Clarification: The SNF CB requirement makes the SNF itself responsible for including on the Part A bill that it submits to its Medicare intermediary almost all of the services that a resident receives during the course of a Medicare-covered stay, except for a small number of services that are specifically excluded from this provision. These “excluded” services can be separately furnished to the resident and billed under Medicare Part B by a variety of outside sources. These sources can include other providers of service (such as hospitals), which would submit the bill for Part B services to their Medicare intermediary, as well as practitioners and suppliers who would generally submit their bills to a Medicare Part B carrier. (Bills for certain types of items or equipment would be submitted by the supplier to their Medicare Durable Medical Equipment Regional Carrier (DMERC)).

Background
When the SNF Prospective Payment System (PPS) was introduced in 1998, it not only changed the way SNFs are paid, but changed the way SNFs must work with suppliers, physicians, and other practitioners.

CB assigns the SNF the Medicare billing responsibility for virtually all of the services that the SNF’s residents receive during the course of a covered Part A stay. Payment for this full range of services is included in the SNF PPS global per diem rate.

The only exceptions are those services that are specifically excluded from this provision, which remain separately billable to Medicare Part B by the entity that actually furnished the service. See Medlearn Matters Special Edition SE0431 at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0431.pdf

It contains a detailed overview of SNF CB and a list of the services excluded from SNF CB.

However, one of the service categories that the law does exclude from the SNF CB provision is physician services, which are separately billable to the Medicare Part B carrier.

Since many diagnostic tests include both a technical component and a professional component, suppliers need to generate two bills. For example, with regard to diagnostic radiology services, such as x-rays, the physician service exclusion applies only to the professional component of the diagnostic radiology service (representing the physician’s interpretation of the diagnostic test).

The physician service is billed directly to the Medicare Part B carrier.

Because the diagnostic radiology service’s technical component is already included within the SNF’s global per diem payment for its resident’s covered Part A stay, the outside supplier that actually furnishes the technical component would look to the SNF (rather than to their Medicare carrier) for payment.

As indicated in the preceding discussion, these policies are not new, and have been in effect since the implementation of the SNF PPS in 1998. What has changed, though, is that the Centers for Medicare & Medicaid Services (CMS) installed electronic edits in 2002 that enable the claims processing system to detect automatically any claims that are inappropriately submitted to Medicare carriers or intermediaries for those services that are already included within the SNF’s global per diem payment for a resident’s covered Part A stay (such as the technical component of diagnostic tests). As discussed above, because these services are already included within the SNF’s payment for its resident’s Medicare-covered stay, an outside entity that furnishes the services must look to the SNF, rather than to Medicare, for payment.

Additional Information
See Medlearn Matters Special Edition SE0431 for a detailed overview of SNF CB. This article lists services excluded from SNF CB and can be found at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0431.pdf

The CMS Medlearn Consolidated Billing Web site can be found at: http://www.cms.hhs.gov/medlearn/snfcode.asp

It includes the following relevant information:

Also, the SNF PPS Consolidated Billing Web site can be found at: http://www.cms.hhs.gov/providers/snfpps/cb

It includes the following relevant information:
• Background,
• Historical questions and answers,
• Links to related articles, and
• Links to publications (including transmittals and Federal Register notices)

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Skilled Nursing Facility Consolidated Billing as It Relates to Certain Types of Exceptionally Intensive Outpatient Hospital Services

NOTE: This article was revised on February 18, 2005, to include clarifying language but no substantive changes were made.

Provider Types Affected
Skilled Nursing Facilities (SNFs), physicians, suppliers, providers, and imaging centers

Clarification: The SNF CB requirement makes the SNF itself responsible for including on the Part A bill that it submits to its Medicare intermediary almost all of the services that a resident receives during the course of a Medicare-covered stay, except for a small number of services that are specifically excluded from this provision. These “excluded” services can be separately furnished to the resident and billed under Medicare Part B by a variety of outside sources. These sources can include other providers of service (such as hospitals), which would submit the bill for Part B services to their Medicare Intermediary, as well as practitioners and suppliers who would generally submit their bills to a Medicare Part B carrier. (Bills for certain types of items or equipment would be submitted by the supplier to their Medicare durable medical equipment regional carrier (DMERC)).

Provider Action Needed
This Special Edition describes SNF Consolidated Billing (CB) as it relates to certain types of exceptionally intensive outpatient hospital services, such as Magnetic Resonance Imaging (MRI) services, Computerized Axial Tomography (CT) Scans, and Radiation Therapy.

Background
When the SNF Prospective Payment System (PPS) was introduced in 1998, it changed not only the way SNFs are paid, but also the way SNFs must work with suppliers, physicians, and other practitioners. CB assigns the SNF itself the Medicare billing responsibility for virtually all of the services that the SNF’s residents receive during the course of a covered Part A stay. Payment for this full range of services is included in the SNF PPS global per diem rate.

The only exce ptions are those services that are specifically excluded from this provision, which remain separately billable to Medicare Part B by the entity that actually furnished the service. For a detailed overview of SNF CB, including a section on services excluded from SNF CB, see Medlearn Matters Special Edition article SE0431 at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0431.pdf

The original CB legislation (Section 4432(b) of the Balanced Budget Act of 1997, P. L. 105-33 (BBA 1997)) specified a list of services at Section 1888(e)(2)(A)(ii) of the Social Security Act that were excluded from this provision. As with the inpatient hospital bundling requirement (Section 1862(a)(14) of the Social Security Act) on which it was modeled, the SNF CB provision excluded primarily the services of physicians and certain other practitioners.

Moreover, these services were excluded categorically, without regard to the specific setting in which they were furnished. This legislation did not authorize the Department of Health and Human Services (DHHS) to create additional categorical exclusions from CB administratively, thereby reserving this authority for the Congress itself. In fact, the Congress subsequently did enact a number of additional CB exclusions that applied uniformly to services furnished in both hospital and non-hospital settings, in Section 103 of the Balanced Budget Refinement Act of 1999 (BBRA 1999, P.L.106-113, Appendix F).

While the original CB legislation did not authorize DHHS to simply carve out entire categories of services from CB without regard to setting, it did define the SNF CB provision in terms of services furnished to a resident of a SNF, and provided a degree of administrative discretion in defining when a beneficiary is considered to be a SNF “resident” for this purpose.

Using this authority, the Centers for Medicare & Medicaid Services (CMS) identified several types of exceptionally intensive outpatient hospital services that were well beyond the general scope of SNF care plans. These services include:

CMS established that a beneficiary’s receipt of such services in the outpatient hospital setting had the effect of temporarily suspending his/her status as a SNF resident for CB purposes, thus enabling the hospital to bill Part B separately for the services. (See Title 42 of the Code of Federal Regulations (42 CFR), Section 411.15(p)(3)(iii).) The underlying rationale for this exclusion was that these services were 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 the legislative history that accompanied the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA, P.L. 108-173), Congress explicitly recognized that this administrative exclusion is specifically limited to “…certain outpatient services from a Medicare participating hospital or critical access hospital…” (emphasis added). (See the House Ways and Means Committee Report (H. Rep. No. 108-178, Part 2 at 209), and the Conference Report (H. Conf. Rep. No. 108-391 at 641)). This means that the exclusion does not encompass services that are furnished in other, non-hospital settings (such as freestanding clinics).

As noted previously, in addition to the existing exclusion of certain types of intensive outpatient hospital services under the regulations at 42 CFR 411.15(p)(3)(iii), Congress has elected to exclude several categories of services from CB in the statute itself, at Sections 1888(e)(2)(A)(ii)-(iii) of the Social Security Act. Unlike the administrative exclusion discussed above, which applies solely to services furnished in the outpatient hospital setting, the statutorily excluded services are separately billable to Part B regardless of the setting (hospital versus freestanding) in which they are furnished.

For example, as amended by Section 103 of BBRA 1999, Section 1888(e)(2)(A)(iii)(II) of the Social Security Act excludes certain types of intensive chemotherapy services, regardless of whether they are furnished in a hospital or freestanding setting. Additional legislation would be required to expand the exemption of CT scans, MRI services, and radiation therapy to apply to services furnished in non-hospital settings.

Chemotherapy and its administration and radioisotopes and their administration are identified in the statute by HCPCS Code. These services are separately billable in all care settings, but the exclusion applies only to the codes specified in the Social Security Act and subsequent regulations. Therefore, other services given in conjunction with an excluded code (e.g., other pharmaceuticals, medical supplies, etc.) remain bundled and should be reimbursed by the SNF to the supplier.

Please note that the professional charge for the physician who performs/interprets the radiological procedure is NOT subject to CB. Since the physician service exclusion applies to the professional component of the diagnostic radiology service, the physician bills his/her service directly to the Medicare Part B carrier for reimbursement.

Additional Information
See Medlearn Matters Special Edition SE0431 for a detailed overview of SNF CB. This article lists services excluded from SNF CB and can be found at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0431.pdf

The Centers for Medicare and Medicaid Services (CMS) Medlearn Consolidated Billing Web site can be found at: http://www.cms.hhs.gov/medlearn/snfcode.asp

It includes the following relevant information:

The SNF PPS Consolidated Billing Web site can be found at: http://www.cms.hhs.gov/providers/snfpps/cb

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Skilled Nursing Facility Consolidated Billing As It Relates to Ambulance Services

Note: This instruction was revised on February 18, 2005 to include clarifying language, but no substantive changes were made.

Provider Types Affected
Skilled Nursing Facilities (SNFs), physicians, ambulance suppliers, and providers

Provider Action Needed
This Special Edition article describes SNF Consolidated Billing (CB) as it applies to ambulance services for SNF residents.

Clarification: The SNF CB requirement makes the SNF responsible for including on the Part A bill that it submits to its Medicare intermediary almost all of the services that a resident receives during the course of a Medicare-covered stay, except for a small number of services that are specifically excluded from this provision. These “excluded” services can be separately furnished to the resident and billed under Medicare Part B by a variety of outside sources. These sources can include other providers of service (such as hospitals), which would submit the bill for Part B services to their Medicare intermediary, as well as practitioners and suppliers who would generally submit thei