Description
Payment for the majority of Skilled Nursing Facility (SNF) services provided to beneficiaries in a Medicare covered Part A stay are included in a bundled prospective payment made through the fiscal intermediary (FI) A/B Medicare Administrative Contractor (MAC) to the SNF. These bundled services are to be billed by the SNF to the FI A/B MAC in a consolidated bill. The consolidated billing requirements confers on the SNF the billing responsibility for the entire package of care that residents receive during a covered Part A SNF stay.
Affected Code(s)
All CPT/HCPCS codes excluding those service codes listed on the CMS File 1 (Part A Stay-Physician Services) CPT/HCPCS code listed on the CMS File 2 billed with modifier TC (Part A Stay-Professional Components of Services)
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 Code of Federal Regulations (CFR) §424.5(a)(6)- Sufficient Information
7. 42 CFR §405.986- Good Cause for Reopening
8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
9. Medicare Claims Processing Manual, CMS Publication 100-04, Chapter 6 (SNF Inpatient Part A Billing and SNF Consolidated Billing), §20.1.1- Physician’s Services and Other Professional Services Excluded From Part A PPS Payment and the Consolidated Billing Requirement
10. SNF Consolidated Billing - Part B Medicare Administrative Contractor (MAC) File Explanation https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/FileExplanation