National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

MMR-2007 12B, December 2007

Additional Common Working File (CWF) Editing for Skilled Nursing Facility (SNF) Consolidated Billing (CB) - Part II

Provider Types Affected
Physicians and providers who bill Medicare carriers or Medicare Administrative Contractors (A/B MAC) for therapy services provided to Medicare beneficiaries in SNF stays  

What Providers Need To Know
Effective for dates of service on or after April 1, 2001, Change Request (CR) 5757, from which this article is taken, instructs Medicare carriers and A/B MACs to modify the existing therapy edit for Part B claims processing to ensure that all therapy services are subjected to SNF consolidated billing edits when provided in a covered or noncovered SNF stay.  

Background
Since therapy services provided in a SNF must be consolidated when a beneficiary is in a SNF stay, whether covered or noncovered by Medicare, Medicare systems will reject claims with dates of service falling within a SNF stay. As a result of this specific change, Medicare’s CWF system will reject claims with dates of service after the posted SNF claim until a discharge claim is processed. The entity furnishing the therapy services must look to the SNF for payment, rather than billing Medicare.

Medicare contractors (carrier or A/B MAC) will reopen and reprocess inappropriately denied claims for dates of service on or after April 1, 2001 through April 6, 2008, when you bring such claims to their attention. You should contact your Medicare contractor to have claims reprocessed that you feel were erroneously subject to these consolidated billing edits, and denied. However, if you received payment directly from the SNF, you must return that payment to the SNF before requesting payment through the Medicare contractor.

Additional Information
You may see the official instruction (CR5757) issued to your Medicare carrier or A/B MAC by going to http://www.cms.hhs.gov/Transmittals/downloads/R1365CP.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site. As an attachment to CR5757, you will find updated Medicare Claims Processing Manual, Chapter 6 (SNF Inpatient Part A Billing), Sections 110.2.2 (A/B Crossover Edits).

If you have questions, please contact your Medicare carrier or A/B MAC, at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site .

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.