July 2023 Quarterly Update to Healthcare Common Procedure Coding System (HCPCS) Codes Used for SNF Consolidated Billing Enforcement

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

The purpose of this Change Request (CR) – 12052 is to provide updates to the lists of HCPCS codes that are subject to the consolidated billing provision of the SNF Prospective Payment System (PPS).

Changes to Current Procedural Terminology/Healthcare Common Procedure Coding System (CPT/HCPCS) codes and Medicare Physician Fee Schedule designations will be used to revise CWF edits to allow MACs to make appropriate payments in accordance with policy for SNF consolidated billing in chapter 6, section 20.6.

The Centers for Medicare & Medicaid Services (CMS) periodically updates the lists of Healthcare Common Procedure Coding System (HCPCS) codes that are excluded from the CB provision of the SNF Prospective Payment System (PPS). Services excluded from SNF PPS and CB may be paid to providers, other than SNFs, for beneficiaries, even when in a SNF stay. Services not appearing on the exclusion lists submitted on claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment MACs (DME MACs), will not be paid by Medicare to any providers other than a SNF. For non-therapy services, SNF CB applies only when the services are furnished to a SNF resident during a covered Part A stay; however, SNF CB applies to physical and occupational therapies and speech-language pathology services whenever they are furnished to a SNF resident, regardless of whether Part A covers the stay. In order to assure proper payment in all settings, Medicare systems must edit for services provided to SNF beneficiaries both included and excluded from SNF CB.

The updated lists for institutional and professional billing are available at: http://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html?redirect=/SNFConsolidatedBilling/.

This Transmittal is 254 pages in length with lots of changes so be sure to provide this information to your billers and reimbursement specialists.