2016 Part B MAC Update

2016 Annual Part B MAC Update

The SNF consolidated billing files reflect new codes that have been developed for 2016 and codes that have been discontinued for 2016. In addition, the files reflect any additions and deletions to categories of services excluded from consolidated billing. These files are effective for claims with dates of service on or after 1/01/2016 unless otherwise noted.

Note: A specific Healthcare Common Procedure Coding System (HCPCS) code was not included in the 2016 annual update to the SNF consolidated billing code editing lists. A correction to the coding lists will be implemented in October 2016. The affected HCPCS code for practitioner billing is 10030, which will be added to File 1. If you have claims with dates of service from January 1 through September 30, 2016, that have been erroneously denied, you should contact your Medicare Administrative Contractor to have the claims re-opened and re-processed.

There is a new HCPCS code (G9678) that will be back dated to July 1, 2016. The affected HCPCS code for practitioner billing will be added to File 1. If you have claims with dates of service from July 1 through December 31, 2016, that have been erroneously denied, you should contact your Medicare Administrative Contractor to have the claims re-opened and re-processed.

There are two new HCPCS codes (G9685 and G9686) that will be back dated to October 1, 2016. The affected HCPCS code for practitioner billing will be added to File 1. If you have claims with dates of service from October 1 through December 31, 2016, that have been erroneously denied, you should contact your Medicare Administrative Contractor to have the claims re-opened and re-processed.

File 1 - Part A Stay - Physician Services (see file below)

Services represented by these codes are not subject to skilled nursing facility (SNF) consolidated billing for Medicare beneficiaries in a SNF Part A covered stay. They should be submitted to the Part B MAC or Durable Medical Equipment MAC, as appropriate, for payment consideration.

The following codes when billed globally, or as a separate technical component or professional component billed with a TC or 26 modifier, are excluded from consolidated billing and may be paid separately by the Part B MAC: 78804, 79200, 79300, 79403, and 79440. These codes therefore appear on both File 1 and File 2.

File 2 - Part A Stay - Professional Components of Services to be Submitted with a 26 Modifier (see file below)

Note: The professional component of the services represented by these codes are not subject to skilled nursing facility (SNF) consolidated billing and will be considered for payment by the Part B MAC for Medicare beneficiaries in a SNF Part A stay. These codes must be submitted with a modifier of 26 to indicate "professional component".

File 3 - Part A Stay - Ambulance (see file below)

Note: These are ambulance codes that will always be denied by the Part B MAC for Medicare beneficiaries in a skilled nursing facility Part A covered stay when submitted with an NN modifier. Effective 10/4/04, per Transmittal 163, these ambulance codes will also be denied when submitted with modifiers ND or DN.

File 4 - Part B Stay Only - Therapy Services (see file below)

Note: Services represented by these codes are the only services subject to skilled nursing facility (SNF) consolidated billing for Medicare beneficiaries in a SNF Part B stay. The file includes codes for physical, occupational and speech therapy. The Part B MAC will always deny these codes for Medicare beneficiaries in a SNF Part B stay. Therapy services must be provided and billed under arrangement with the SNF.