Regulatory Reminders: SNF Consolidated Billing Update

No rest for the weary on this beautiful Spring day. CMS has just released Transmittal 10770 along with an MLN Matters article MM12271  October Quarterly Update to 2021 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement to update the list of items and services that will be excluded from consolidated billing starting with dates of service on or after October 1, 2021.

Consolidated Billing What is It?

In the Balanced Budget Act of 1997, Congress mandated that payment for the majority of services provided to beneficiaries in a Medicare covered SNF stay be included in a bundled prospective payment made through the Part A Medicare Administrative Contractor (MAC) to the SNF. These bundled services had to be billed by the SNF to the Part A MAC in a consolidated bill. No longer would entities that provided these services to Medicare beneficiaries in a Part A covered SNF stay be able to bill separately for those services.

The consolidated billing requirement confers on the SNF the billing responsibility for the entire package of care that residents receive during a covered Part A SNF stay and physical, occupational, and speech therapy services received during a non-covered stay.

Exception: However, there are a limited number of services specifically excluded from consolidated billing, and therefore, separately payable. There are two websites that are helpful resources for current information related to consolidated billing, Consolidated Billing and SNF Consolidated Billing.

Excluded Services

Every year, CMS posts a document called the General Explanation of the Major Categories for Skilled Nursing Facility (SNF) Consolidated Billing.This document is a helpful summary of the categories, items and services that are excluded from consolidated billing. These guidelines are more thoroughly discussed in the Medicare Claims Processing Manual Chapter 6 – SNF Inpatient Part A Billing and SNF Consolidated Billing. CMS has also posted Historical Questions & Answers on SNF Consolidated Billing that offers further clarity on some of the key consolidated billing principles.

For Medicare beneficiaries in a covered Part A stay, these separately payable, or excluded, services include select items or services in the following categories:

  • physician’s professional services;
  • certain dialysis-related services, including covered ambulance transportation to obtain the dialysis services;
  • certain ambulance services, including ambulance services that transport the beneficiary to the SNF initially, ambulance services that transport the beneficiary from the SNF at the end of the stay (other than in situations involving transfer to another SNF), and roundtrip ambulance services furnished during the stay that transport the beneficiary offsite temporarily in order to receive dialysis, or to receive certain types of intensive or emergency outpatient hospital services;
  • erythropoietin for certain dialysis patients;
  • certain chemotherapy drugs;
  • certain chemotherapy administration services;
  • radioisotope services; and
  • customized prosthetic devices.

What’s Changing On October 1st?

As noted above, CMS just released updated guidance related to the list of items and services that will be excluded from consolidated billing starting with dates of service on or after October 1, 2021.

This update is interesting since the items added to the list of excluded items were, up until these notifications, only part of CMS’ FY 22 proposed rule which was released in April and has not been finalized. Nonetheless, CMS appears to have finalized its decision to add blood clotting factors indicated for the treatment of hemophilia and other bleeding disorders to the statutory list of excluded services starting with dates of service on or after October 1, 2021.

You can read more about this action and its effect on the proposed FY 22 PDPM base rates in our recent blog post, SNF FY 2022 Proposed Rule – Learn the Facts Behind the Headlines Part 3: How is My Rate Calculated.

The specific list of blood clotting factors that will be excluded are listed in the transmittal and MLN Matters article linked above. Also, annually, CMS updates the official complete list of excluded items and services in a Part A MAC update. This is usually posted prior to when annual revisions will take effect. For an in-depth discussion of the full SNF FY 2022 Proposed rule, you may access our recent Broad River Rehab Reflection webcast CMS Proposed Rule! Learn the Facts Beyond the Headlines.