SURGERY GROUND RULES

PACKAGE OR GLOBAL FEE CONCEPT: Listed surgical procedures include the surgery itself, local anesthesia, metacarpal/digital block, or topical anesthesia when used, and normal, uncomplicated follow-up care. The Unit Values for all procedures in this section applies to this "package" or "global" service for surgical procedures. To report a postoperative follow-up for documentation purposes only, use 99024 (see Special Services and Reports Section). For preoperative visits, see Ground Rules 3 and 4 below; see the respective Anesthesia Ground Rule pertaining to anesthesia administered by other than an anesthesiologist or anesthetist. 

OPERATIVE REPORT AND BILLING: A bill for an operative procedure shall be deemed properly submitted only if an operative report or an informative description of the surgery performed is received by the payer. If surgery was performed in a hospital or an ambulatory surgery center, a copy of the hospital's or ambulatory surgery center's operative report will suffice. If surgery was performed at some other site and classified as minor surgery, such as at a physician's office, identify the (geographic) location and submit an informative description of the surgery performed. 

IMMEDIATE PREOPERATIVE VISITS AND OTHER SERVICES BY THE SURGEON: Under most circumstances, including ordinary referrals, the immediate preoperative visit in the hospital or elsewhere that is necessary to examine the patient, or to initiate the treatment program, is included in the Unit Value listed for the surgical procedure.

SEPARATE PREOPERATIVE CHARGES: Charges for separate preoperative procedures are sometimes warranted and may be billed under the following circumstances: 

a) when the preoperative visit is the initial visit (e.g., an emergency) and prolonged detention or evaluation is required to prepare the patient, or to establish the need for and type of surgical procedure. 

ANESTHESIA

CPT Code Base Unit Value

00100 $255.95 + TM*

00400 $153.57 + TM*

00632 $358.33 + TM*

00102 $307.14 + TM*

00402 $255.95 + TM*

00634 $511.90 + TM*

00103 $255.95 + TM*

 00404 $255.95 + TM*

 00635 $204.76 + TM*

00104 $204.76 + TM*

00406 $665.47 + TM*

00640 $153.57 + TM*

00120 $255.95 + TM*

00410 $204.76 + TM*

00670 $665.47 + TM*

00124 $204.76 + TM*

00474 $665.47 + TM*

00752 $307.14 + TM*

00126 $204.76 + TM*

00500 $767.85 + TM*

00754 $358.33 + TM*

00140 $255.95 + TM*

00520 $307.14 + TM*

00756 $358.33 + TM*

00142 $204.76 + TM*

00522 $204.76 + TM*

 00770 $767.85 + TM*

00144 $307.14 + TM*

00524 $204.76 + TM*

00790 $358.33 + TM*

00145 $307.14 + TM*

00528 $409.52 + TM*

00792 $665.47 + TM*

00147 $204.76 + TM*

00529 $563.09 + TM*

00794 $409.52 + TM*

00148 $204.76 + TM*

00530 $204.76 + TM*

00796 $1535.70 + TM*

00160 $255.95 + TM*

00532 $204.76 + TM*

00797 $563.09 + TM*

00162 $358.33 + TM*

00534 $358.33 + TM*

00800 $204.76 + TM*

00164 $204.76 + TM*

 00537 $358.33 + TM*

00802 $255.95 + TM*

00170 $255.95 + TM*

00539 $921.42 + TM*

00810 $255.95 + TM*

00172 $307.14 + TM*

00540 $614.28 + TM*

 00820 $255.95 + TM*

00174 $307.14 + TM*

00541 $767.85 + TM*

00830 $204.76 + TM*

00176 $358.33 + TM*

00542 $767.85 + TM*

00832 $307.14 + TM*

00190 $255.95 + TM*

00546 $767.85 + TM*

00834 $255.95 + TM*

00192 $358.33 + TM*

00548 $870.23 + TM*

00836 $307.14 + TM*

 00210 $563.09 + TM*

00550 $511.90 + TM*

00840 $307.14 + TM*

00211 $511.90 + TM*

00560 $767.85 + TM*

00842 $204.76 + TM*

00212 $255.95 + TM*

00561 $1279.75 + TM*

00844 $358.33 + TM*

00214 $460.71 + TM*

00562 $1023.80 + TM*

00846 $409.52 + TM*

00215 $460.71 + TM*

00563 $1279.75 + TM*

00848 $409.52 + TM*

00216 $767.85 + TM*

00566 $1279.75 + TM*

00851 $307.14 + TM*

00218 $665.47 + TM*

00567 $921.42 + TM*

00860 $307.14 + TM*

00220 $511.90 + TM*

00580 $1023.80 + TM*

00862 $358.33 + TM*

00222 $307.14 + TM*

00600 $511.90 + TM*

00864 $409.52 + TM*

00300 $255.95 + TM*

00604 $665.47 + TM*

00865 $358.33 + TM*

00320 $307.14 + TM*

00620 $511.90 + TM*

00866 $511.90 + TM*

00322 $153.57 + TM*

 00622 $665.47 + TM*

00868 $511.90 + TM*

00326 $358.33 + TM*

00625 $665.47 + TM*

00870 $255.95 + TM*

00350 $511.90 + TM*

00626 $767.85 + TM*

00872 $358.33 + TM*

00352 $255.95 + TM*

00630 $409.52 + TM*

00873 $255.95 + TM*

00880 $767.85 + TM*

01212 $511.90 + TM*

01610 $255.95 + TM*

00882 $511.90 + TM*

01215 $511.90 + TM*

01622 $204.76 + TM*

00902 $255.95 + TM*

01220 $204.76 + TM*

01630 $255.95 + TM*

00904 $358.33 + TM*

01230 $307.14 + TM*

01634 $460.71 + TM*

00906 $204.76 + TM*

01232 $255.95 + TM*

01636 $767.85 + TM*

00918 $255.95 + TM*

COST CONTAINMENT

Nothing in this section shall preclude an employer (or insurance carrier) from entering into payment agreements to promote the continuity of care and the reduction of health care costs. Such payment agreements, if less, will supersede the limitation amounts specified herein. Please refer to K.S.A 44-510i(e) for further clarification, if necessary.

NATIONAL CORRECT CODING INITIATIVE (NCCI) EDITS: In order to promote correct coding methodologies and to control improper coding leading to inappropriate payments, the Kansas Division of Workers Compensation Schedule of Medical Fees recognizes the 2014 National Correct Coding Initiatives (NCCI) Edits as established by the Centers for Medicare and Medicaid Services (CMS) as the primary standard of reference. The NCCI Edits are not requirements, nor are they mandates or standards; they simply provide advice for correct coding methodologies. Bills must be itemized by procedure code, date of service, and amount of charge.  

CALCULATION EXAMPLES:

1: In a procedure with a Basic Unit Value of 3.0 requiring one hour and forty-five minutes of anesthesia time, the total value should be determined as follows: 

 Basic Unit Value = 3.0 units 

 105 minutes÷15 minutes = 7.0 units 

 Total value = 10.0 units 

2: In a procedure with a Basic Unit Value of 10.0 requiring four hours and twenty minutes of anesthesia time, the total value should be determined as follows:

Basic Unit Value = 10.0 units 

 First three hours = 12.0 units 

 Subsequent 80 minutes = 8.0 units 

 Total value = 30.0 units 

SUPPLEMENTAL SKILLS

When warranted by the necessity of supplemental skills, values for the services of two or more health care providers and/or anesthetists will be allowed. Substantiate by report.

MONITORING SERVICES: When an anesthesiologist or anesthetist is required to participate in and be responsible for monitoring the general care of the patient during a surgical procedure but does not administer anesthesia, these services are charged on the basis of the extent of the services rendered. Payment is to be made on the basis of the time units the anesthesiologist or anesthetist is in constant attendance for the sole purpose of the monitoring services; therefore, basic unit values are not to be added.  

ANESTHESIA ADMINISTERED, OTHER THAN BY AN ANESTHESIOLOGIST OR ANESTHETIST: Anesthesia fees are not payable when local infiltration, digital block, or topical anesthesia is administered by the operating surgeon or surgical assistants. Such services are included in the Unit Value for the surgical procedure. 

OTHER FEES: The Unit Values for surgery, x-rays, laboratory procedures, consultation and other medical services, and office and hospital visits are listed in the following sections: Surgery, Radiology, Pathology and Laboratory, Medicine, Physical Medicine and Rehabilitation, and Evaluation and Management. A consultation fee is not payable to an anesthesiologist examining the patient prior to administering anesthesia to that patient. No additional charge is to be made for routine follow-up care and observation. 

QUALIFYING CIRCUMSTANCES (more than one may be reported): Many anesthesia services are provided under particularly difficult circumstances depending on factors such as the extraordinary condition of the patient, notable operative conditions, unusual risk factors. This section includes a list of important qualifying circumstances that significantly impact on the character of the anesthetic service provided. These procedures would not be reported alone but would be reported as additional procedure numbers qualifying an anesthesia procedure or service. These modifying units may be added to the basic unit values. 

ANESTHESIA MODIFIERS

All anesthesia services are reported by use of the anesthesia five-digit procedure code plus the addition of a physical status modifier. These modifying units may be added to the basic unit value. The use of other optional modifiers may also be appropriate.

Physical Status Modifiers 

Physical status modifiers are represented by the initial letter P followed by a single digit from 1 to 6 as defined below:  

P1 - A normal healthy patient .................................................................................................. 0 

P2 - A patient with mild systemic disease .................................................................................. 0 

P3 - A patient with severe systemic disease ............................................................................... 1 

P4 - A patient with severe systemic disease that is a constant threat to life ............................... 2 

P5 - A moribund patient who is not expected to survive without the operation .......................... 3

P6 - A declared brain-dead patient whose organs are being removed for donor purposes ....................................................................................................................................................... 0 

The above six levels are consistent with the American Society of Anesthesiologists (ASA) ranking of patient physical status. Physical status is included in CPT to distinguish between various levels of complexity of the anesthesia service provided.

TIME UNITS (TM): TIME UNITS WILL BE ADDED TO THE BASIC UNIT VALUE AND MODIFYING UNITS AS IS CUSTOMARY IN THE LOCAL AREA. Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area, and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under other post-anesthesia supervision. 

The time units are calculated by allowing one unit for each 15 minutes or significant fraction thereof (7.5 minutes or more) of anesthesia time. If anesthesia time extends beyond three hours, 1.0 unit for each 10 minutes or significant fraction thereof (5 minutes or more) is allowed after the first three hours. Documentation of actual anesthesia time may be required, such as a copy of the anesthesia record in the hospital file.  

UNLISTED SERVICE OR PROCEDURE: When an unlisted service or procedure is performed, the values used should be substantiated "By Special Report." For an unlisted service or procedure, the health care provider or anesthetist shall establish a unit value consistent with other unit values listed in the schedule. 

MATERIALS SUPPLIED BY HEALTH CARE PROVIDER: Supplies and materials provided by the health care provider or anesthetist (e.g., sterile trays, drugs) over and above those usually included with the office visit or other services rendered may be listed separately. The statement of charges will need to reflect any drugs, trays, supplies, and materials that were provided. Payment shall not exceed the cost of the item(s) to the health care provider plus 25%, or the cost of the item(s) plus $15.00 per item, whichever is less. Use procedure code 99070

MODIFIER EXAMPLES

1: A physician providing diagnostic or therapeutic radiology services, ultrasound, or nuclear medicine services in a hospital would use modifier -26 to report the professional component, as follows:

 73090-26 = Professional component only for an x-ray of the forearm 

2: Two surgeons, usually with different skills, may be required to manage a specific surgical problem. The modifier -62 would be applicable. Modifier -62 would be appropriate only when both surgeons are reporting the same code number and descriptor. For instance, a neurological surgeon and an otolaryngologist are working as cosurgeons in performing transsphenoidal excision of a pituitary neoplasm. The first surgeon would report: 

61548-62 = Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic + two surgeons modifier AND the second surgeon would report: 

61548-62 = Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic + two surgeons modifier 

ANESTHESIA GROUND RULES

GENERAL: All anesthesia values are determined by taking the BASIC UNIT VALUE, which is related to the complexity of the service, and adding MODIFYING UNITS (if any), and TIME UNITS. The fee for a particular procedure or service in this section is determined by multiplying the listed "Basic Unit Value" by the conversion factor that is applicable to this section. . 

The values contained within this section apply when the anesthesia care is provided by or under the medical supervision of qualified physician. This anesthesia care may include but is not limited to general, regional, monitored anesthesia care, supplementation of local anesthesia, or other supportive services in order to afford the patient the anesthesia care deemed optimal. For anesthesia care provided by nurse anesthetists, billing for independent unsupervised services, payment will be limited to 85% of the maximum allowable fee associated with the CPT code submitted. 

Medicare

The Medicare allowed charge for the services is the lower of the actual charge or the MPFS amount. The Medicare payment for the services is 80 percent of the allowed charge after the Part B deductible is met. Coinsurance is made at 20 percent of the lower of the actual charge or the MPFS amount. The general coinsurance rule (20 percent of the actual charges) does not apply when making payment under the MPFS. This is a final payment.

The MPFS does not apply to outpatient rehabilitation services furnished by critical access hospitals (CAHs). CAHs are to be paid on a reasonable cost basis.

Contractors process outpatient rehabilitation claims from hospitals, including CAHs, SNFs, HHAs, CORFs, outpatient rehabilitation agencies, and outpatient physical therapy providers for which they have received a tie in notice from the RO. These provider types submit their claims to the contractors using the 837 Institutional electronic claim format or the UB-04 paper form when permissible. Contractors also process claims from physicians, certain nonphysician practitioners (NPPs), therapists in private practices (TPPs), (which are limited to physical and occupational therapists, and speech-language pathologists in private practices), and physiciandirected clinics that bill for services furnished incident to a physician’s service (see Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, for a definition of “incident to”). These provider types submit their claims to the contractor using the 837 Professional electronic claim format or the CMS-1500 paper form when permissible.

There are different fee rates for nonfacility and facility services. Chapter 23 describes the differences in these two rates. (See fields 28 and 29 of the record therein described). Facility rates apply to professional services performed in a facility other than the professional’s office. Nonfacility rates apply when the service is performed in the professional’s office. The nonfacility rate (that is paid when the provider performs the services in its own facility) accommodates overhead and indirect expenses the provider incurs by operating its own facility. Thus it is somewhat higher than the facility rate

Contractors pay the nonfacility rate on institutional claims for services performed in the provider’s facility. Contractors may pay professional claims using the facility or nonfacility rate depending upon where the service is performed (place of service on the claim), and the provider specialty.

Contractors pay the codes in §20 under the MPFS on professional claims regardless of whether they may be considered rehabilitation services. However, contractors must use this list for institutional claims to determine whether to pay under outpatient rehabilitation rules or whether payment rules for other types of service may apply, e.g., OPPS for hospitals, reasonable costs for CAHs.

Note that because a service is considered an outpatient rehabilitation service does not automatically imply payment for that service. Additional criteria, including coverage, plan of care and physician certification must also be met

Glaucoma Screening

The Benefits Improvement and Protection Act of 2000, §102, provides annual coverage for glaucoma screening for Medicare beneficiaries with diabetes mellitus, or a family history of glaucoma, or African-Americans age 50 and over. 

Payment is made under the Medicare Physician's Fee Schedule (MPFS).

Billing for Laboratory Tests Under Part B - General

Section 1833(h)(5) of the Act (as enacted by The Deficit Reduction Act of 1984, Public Law 98-369) requires the establishment of a fee schedule for clinical diagnostic laboratory tests paid under Part B.

Section 1833g(5)(A)iii of Title XVIII provides that "in the case of a clinical diagnostic laboratory test provided under an arrangement (as defined in §1861(w)(1)) made by a hospital, critical access hospital or skilled nursing facility, payment shall be made to the hospital or skilled nursing facility."

SNFs must make arrangements under Part A and may make arrangements under Part B under which the SNF bills the intermediary and receives payment. Under this process, the SNF pays the lab for services whatever amount the SNF and the lab agree on, and the beneficiary may not be charged by the lab.

Where the SNF and a lab have entered into such an arrangement, the arrangement may include Part A only or may include Part A and Part B. Such an arrangement is voluntary on the part of both the lab and the SNF for Part B services.

In the absence of such an arrangement under Part B, the lab may bill the program for lab services furnished to residents for whom Part A cannot be paid, and for SNF outpatients, and the SNF may not bill the program for these services. Hospital labs and labs in other SNFs would bill the intermediary. Independent labs would bill the carrier.

Laboratory tests performed for the SNF's Medicare inpatients covered under Part A are included in the PPS SNF payment.

If the FI receives fee amounts for HCPCS included on both the clinical diagnostic laboratory fee schedule and the SNF extract of the MPFS, the SNF receives the amount on the laboratory fee schedule.

Bill type 22X for lab services to Part B residents and 23X for nonresidents should be used.

Neither deductible nor coinsurance applies to lab fee schedule payments

Glucose Monitoring

Medicare Part B may pay for a glucose monitoring device and related disposable supplies under its durable medical equipment benefit if the equipment is used in the home or in an institution that is used as a home.

Routine glucose monitoring of diabetics is never covered in a SNF, whether the beneficiary is in a covered Part A stay or not. Glucose monitoring may only be covered when it meets all the conditions of a covered laboratory service, including use by the physician in modifying the patient's treatment.

Epoetin (EPO) 

EPO is a biologically engineered protein which stimulates the bone marrow to make new red blood cells. Patients with anemia associated with chronic renal failure include all ESRD patients regardless of whether they are on dialysis. 

EPO is covered for the treatment of anemia for patients with chronic renal failure who are receiving dialysis when it is administered in a renal dialysis facility (RDF). 

EPO is not included in SNF PPS and may be billed separately when given in conjunction with dialysis by the Renal Dialysis Facility. It must be billed by the RDF. 

EPO is not a SNF outpatient benefit.

Diagnostic and Screening Mammograms Performed With New Technologies

Section 104 of the Benefits Improvement and Protection Act 2000, (BIPA) entitled "Modernization of Screening Mammography Benefit," provides for new payment methodologies for both diagnostic and screening mammograms that utilize advanced new technologies for the period April 1, 2001, through December 31, 2001. 

Screening Pap Smears

Sections 1861(s)(14) and 1861(nn) of the Act, (as enacted by §6115 of the Omnibus Budget Reconciliation Act of 1989) provides for coverage of screening pap smears for services provided on or after July 1, 1990. Screening pap smears are laboratory tests consisting of a routine exfoliative cytology test (Papanicolaou test) provided for the purpose of early detection of cervical cancer. It includes a collection of the sample of cells and a physician's interpretation of the test.

Payment is made under the clinical diagnostic laboratory fee schedule.

 Screening Pelvic Examinations

Section 4102 of the BBA of 1997 (P.L. 105-33) amended §1861(nn) of the Act (42 USC 1395X(nn)) to include coverage of screening pelvic examinations for all female beneficiaries for services provided January 1, 1998, and later. Effective July 1, 2001, the Consolidated Appropriations Act of 2001 (P.L. 106-554) modifies §1861(nn) to provide Medicare coverage for biennial screening pelvic examinations.

Payment is made under the Medicare Physician's Fee Schedule (MPFS).

Prostate Cancer Screening

Sections 1861(s)(2)(P) and 1861(oo) of the Act (as added by §4103 of the Balanced Budget Act of 1997), provide for coverage of certain prostate cancer screening tests subject to certain coverage, frequency, and payment limitations. Effective for services furnished on or after January 1, 2000, Medicare covers prostate cancer screening tests/procedures for the early detection of prostate cancer. Coverage of prostate cancer screening tests includes the following procedures furnished to an individual for the early detection of prostate cancer:

• Screening digital rectal examination; and 

• Screening prostate specific antigen (PSA) blood test

Each test may be paid at a frequency of once every 12 months for men who have attained age 50 (i.e., starting at least one day after they have attained age 50), if at least 11 months have passed following the month in which the last Medicare-covered screening digital rectal examination was performed (for digital rectal exams) or PSA test was performed (for PSA tests).

Payment is made under the clinical diagnostic laboratory fee schedule.

Colorectal Cancer Screening

Effective for services furnished on or after January 1, 1998, payment may be made for colorectal cancer screening for the early detection of cancer. For screening colonoscopy services (one of the types of services included in this benefit) prior to July 2001, coverage was limited to high-risk individuals. For services July 1, 2001, and later, screening colonoscopies are covered for individuals not at high risk. Screening colonoscopies are not payable to the SNF. Screening colonoscopies are only covered when rendered in a hospital or CAH.

For all other colorectal screening services payment is made under the MPFS or the clinical diagnostic laboratory fee schedule based on the service rendered.

Determining Payment and Patient Liability

There may be prosthetic and orthotic devices, for which the SNF would bill that are not included in the fee schedule. When fee schedule amounts are not available for a particular item, the intermediary will pay based on cost.

To determine the SNF's Part B payment, the SNF subtracts any unmet Part B deductible from the lower of the actual charge or the fee schedule amount for the item or service and multiply the remainder by 80 percent. This is the final payment. The patient's liability is the remaining 20 percent plus any deductible remaining to be met.

Billing for Enteral and Parenteral Nutritional Therapy as a Prosthetic Device

Parenteral nutritional (PEN) therapies including the necessary equipment, medical supplies and nutrients provided to an inpatient (where Part A payment cannot be made), or to individuals who are not inpatients are covered as a prosthesis under the Part B prosthetic device benefit as long as the requirements in the Coverage Manual are met, and the required documentation is submitted.

The SNF or the supplier must bill the DME MAC. The SNF or supplier should refer to the most recent HCPCS directory or billing instructions distributed by the DME MAC for current HCPCS coding information. If the SNF bills the DME MAC., it must obtain a supplier number from the National Supplier Clearinghouse and must use the ASC X12 837 professional claim format, or if permissible Form CMS-1500.

Drugs

Drugs and biologicals furnished to outpatients for therapeutic purposes that are selfadministered are not covered by Medicare unless those drugs and biologicals must be put directly into an item of durable medical equipment or a prosthetic device. Exceptions to this rule are:

• Self administered drugs administered in an emergency situation; 

• Self-administered oral versions of covered injectable cancer drugs prescribed as an anti-cancer chemotherapeutic; 

• Self-administered anti-emetic drugs; 

• Oral anti-emetic drugs as full therapeutic replacements for intravenous dosage forms as part of a chemotherapeutic regimen provided that the drug(s) be administered or prescribed by a physician for use immediately before, at, or within 48 hours after the time of administration of the chemotherapeutic agent; and • Immunosuppressive drugs furnished to transplant patients.

Audiologic Tests

Audiologic tests will generally be billed to the carrier by the provider of service. For tests that include both a professional component and technical component, the SNF may elect to bill the technical component to the intermediary, but is not required to bill the service. 

Payment to SNFs for audiologic tests are bundled into the PPS payment amount for beneficiaries in a covered SNF Part A stay, whether provided directly by the SNF or under arrangements by an independent provider based on a contract with the SNF. Independent audiologists may bill the carrier directly for services rendered to beneficiaries not in a SNF Part A covered stay. For beneficiaries not in a covered Part A SNF stay, who are sometimes referred to as beneficiaries in a Part B SNF stay, audiologic tests are payable under Part B when billed by the SNF as type of bill 22X, or when billed directly to the carrier by the provider of the service. Payment is based on the Medicare Physician Fee Schedule (MPFS), whether by the carrier or the intermediary.

Since audiologic tests are not bundled with speech -language pathology services, payment is made to the provider of service or to the SNF where the services are provided under arrangements with the SNF for SNF outpatients.

Billing Part B Radiology Services and Other Diagnostic Procedures 

Acceptable HCPCS codes for radiology and other diagnostic services are taken primarily from the CPT-4 portion of HCPCS. Payment is the lower of billed charges or the fee schedule amount. In either case, any applicable deductible and coinsurance amounts are subtracted from the payment amount prior to payment. Coinsurance is calculated on the Medicare payment amount after the subtraction of any applicable deductible amount.

• Contrast material other than low osmolar contrast material (LOCM) for radiology; 

• LOCM;

• Radiopharmaceuticals; 

• IV Persantine;

• Transportation of equipment; 

• Position Emission Tomography (PET); and 

• Adenosine.

Bone Mass Measurements

Sections 1861(s)(15) and §1861(rr)(1) of the Act (as added by §4106 of the Balanced Budget Act (BBA) of 1997) standardized Medicare coverage of medically necessary bone mass measurements by providing for uniform coverage under Medicare Part B.

Use of Healthcare Common Procedure Coding System (HCPCS)

HCPCS is required for reporting all SNF services paid under Part B, whether paid by Medicare fee schedules or by some other mechanism

The SNF should use the CPT-4 portion of HCPCS and/or Level II as directed by the manual sections applicable to the Part B service that is being billed. Currently, HCPCS codes are not applicable on SNF Part A inpatient claims.

For Part B claims, there are separate codes for the technical component, professional component, and/or complete procedure. Generally, SNFs bill for the technical component only, using the code that describes the procedure provided.

There may be specific rules for use of HCPCS codes for specific types of services (e.g., SNF's must bill global services for therapies). These will be described in the manual sections for the applicable service.

Revenue codes, HCPCS codes, line item dates of service, and units are required. Charges must be reported by HCPCS code. If the same revenue code applies to two or more HCPCS codes, the SNF should repeat the revenue code and show the line item date of service, units and charge for each HCPCS code on a separate line.

Billing Formats

The SNF must use the current ASC X12 837 institutional claim format or if permissible Form CMS-1450 to bill for covered Part B services

Frequency of Billing for Skilled Nursing Facilities (SNFs)

SNFs must bill repetitive Part B services on a single individual monthly bill (or at the conclusion of treatment). This avoids Medicare processing costs in holding such bills for monthly review and reduces bill processing costs for relatively small claims.

Other one-time Part B services must be billed upon completion of the services.

Guidelines for Submitting Corrected Bills 

When a SNF or intermediary discovers an error on an original bill, there are three methods for correcting the bill depending on the type of error. The SNF or intermediary may submit a late charge bill, an adjustment request, or maintain a log of charges.

 Billing Part B Rehabilitation Services 

Part B rehabilitation services other than audiology services must be billed by the SNF for Part A inpatients, for Part B residents (those not in a covered Part A stay) and for outpatients. Effective January 1, 1999, the MPFS is the payment basis for these services.

Billing for Outpatient SNF Services

Coverage is available for all of the services described in §10.1. However, beneficiaries not in the Medicare-certified Distinct Part Unit (DPU) are not required to have therapy services (physical therapy, occupational therapy, and speech language pathology) billed by the SNF. Therapy services need only be bundled to the SNF for those SNF residents in a Medicare-certified DPU.

Determining How Much to Charge Before Billing Is Submitted 

The SNF may be able to determine from the SNF's records, from a transferring hospital, or from the patient the extent to which the Part B cash deductible is met. The SNF may charge the patient for the unmet deductible and coinsurance. The SNF should submit a bill even if no payment can be made because the unmet Part B cash deductible exceeds the covered charges. In addition, a bill is required when the SNF becomes aware that no bill has been submitted for covered services even though the time limitation for filing has expired.

Charges for Services Provided in Different Accounting Years

The SNF must not put charges for services provided in different accounting years on the same bill. At the end of the SNF's accounting year, the SNF should submit a bill that contains the charges for all services furnished to the patient since the last bill through the end of the year. The SNF should include bills in which the deductible covers all charges. All services furnished in the succeeding accounting year should be placed on a separate bill. Complete all items on the subsequent bill.

General Payment Rules and Application of Part B Deductible and Coinsurance

Section 1888(e)(9) of the Social Security Act (the Act) requires that the payment amount for Part B SNF services shall be the amount prescribed in the otherwise applicable fee schedule. Thus, where a fee schedule exists for the type of service, the fee amount will be paid. Where a fee does not exist on the Medicare Physician Fee Schedule (MPFS) the particular service is priced based on cost. This is also true for all “carrier-priced” codes on the MPFS, but not for services paid on the Clinical Diagnostic Laboratory Fee Schedule. All lab services missing fees are to be gap-filled. Some specific services continue to be paid on a cost basis and are specifically stated in the sections below where cost applies.

Where payment is made under a fee schedule, the beneficiary's deductible and coinsurance are based on the approved amount. Where payment is made on a cost basis, deductible and coinsurance are based on charges for the service.

Billing for Inpatient SNF Services Paid Under Part B

When the beneficiary in a Medicare-certified SNF is not entitled to Part A benefits, limited benefits are provided under Part B. Reasons for not being entitled to have payment made under Part A are that:

• The beneficiary does not have Medicare Part A Health Insurance; 

• The beneficiary is not in a Medicare-certified bed; 

• The inpatient stay is not at a covered level of care and no Part A program payment is possible; or 

• The inpatient stay is not covered because the beneficiary did not have a 3-day qualifying stay.

When no Part A program payment is possible, some or all services may be medically necessary and can be covered as ancillary services under Part B. The following services may be billed by the SNF or the rendering provider or supplier under an arrangement with the SNF:

• Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests; 

• X-ray, radium, and radioactive isotope therapy, including materials and services of technicians; 

• Surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations; 

• Prosthetic devices (other than dental) which replace all or part of an internal body organ (including contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body organ, including replacement or repairs of such devices; 

• Leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes including adjustments, repairs, and replacements required because of breakage, wear, loss, or a change in the patient’s physical condition;

• Screening mammography services; 

• Screening pap smears;

• Influenza, pneumococcal pneumonia, and hepatitis B vaccines; 

• Colorectal screening; 

• Bone mass measurements; 

• Diabetes self-management; 

• Prostate screening; 

• Ambulance services;

• Hemophilia clotting factors for hemophilia patients competent to use these factors without supervision);

• Immunosuppressive drugs; 

• Oral anti-cancer drugs;

• Oral drug prescribed for use as an acute anti-emetic used as part of an anticancer chemotherapeutic regimen; and

• Epoetin Alfa (EPO).

Outpatient physical therapy, outpatient speech-language pathology services, and outpatient occupational therapy (see Chapter 10, §§60) are billable services for SNF inpatients not in a Part A stay. However, they must be billed by the SNF even when another entity renders the services under an arrangement with the SNF.

The determination of whether to use TOB 22x or 23x is a function of the type of facility in which the beneficiary resides. If the facility is not Medicare-certified, it is not a SNF, although it may have a Medicare-certified distinct part unit (DPU). If the beneficiary is in a SNF or SNF DPU, Part B services must be billed on TOB 22x.

All services rendered to SNF patients residing in the non-Medicare-certified portion of an institution that is not primarily engaged in the provision of skilled services must be billed on TOB 23x. Beneficiaries residing in such portions of the facility are considered outpatients of the SNF for Medicare purposes.

If the entire facility qualifies as a Medic are-certified SNF, all Part B services rendered to residents are billed on TOB 22x