The Centers for Medicare & Medicaid Services (CMS) recently released a updated list of the Healthcare Common Procedure Coding System (HCPCS) subject to the Consolidated Billing (CB) provision of the Skilled Nursing Facility (SNF) Prospective Payment System (PPS). The effective date of the HCPCS updates is October 1, 2021, with an implementation date of October 4, 2021.
CMS uses changes to Current Procedural Terminology (CPT) and HCPCS codes and Medicare Physician Fee Schedule (MPFS) designations to revise Common Working File (CFW) edits. This allows the Medicare Administrative Contractors (MACs) to make correct payments in accordance with policy for SNF CB.
CMS periodically updates the lists of HCPCS codes that are excluded from the CB billing under the SNF PPS. Medicare pays providers, other than SNFs, for services that are excluded from SNF PPS and CB for patients, even when in a SNF stay. Medicare will not pay any providers other than the SNF for services not appearing on the exclusion lists.
For non-therapy services, SNF CB applies only when the services are provided 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 services are provided to a SNF resident, regardless of whether Part A covers the stay. To ensure proper payment in all settings, Medicare systems edits for services provided to SNF patients both included and excluded from SNF CB.
Section 1888 of the Social Security Act codifies PPS and CB. Typically, the new coding that is identified in each update describes the same services subject to SNF PPS payment by law. CMS does not add additional services by these routine updates. These updates are due to coding system changes, not because CMS is redefining the services subject to SNF CB.
The effective items and services provided on or after October 1, 2021, Section 134 in Division CC of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260) added certain blood clotting factors indicated for the treatment of hemophilia and other bleeding disorders to the statutory list of excluded service codes.
A complete list of excluded items and services provided on or after October 1, 2021, Section 134 in Division CC of the Consolidated Appropriation ACT 2021 can be accessed here. CMS’ SNF Consolidated Billing Learning page can be accessed here.
Compliance Perspective
Issue
It is essential that your billing department is aware of all changes to HCPCS/CPT codes in order to bill accurately. If the billing department is not aware of changes, or inadvertently bills inaccurately, it could result in a false claim. All members of the billing department should be aware of what a false claims is and best practices to avoid false claims. If a false claim is discovered, it should be reported immediately, whether it was intentional or submitted in error. Failure to promptly report a false claim can result in charges of fraud, in the issuing of fines, or in other sanctions. Additional information is available in the Med-Net Corporate Compliance and Ethics Manual, Chapter 2 Financial Integrity, FI 2.1 Billing Management.
Discussion Points
- Review your policy and procedure on billing services and for preventing and reporting a false claim violation. Update your policies and procedures as needed.
- Train your billing department on updated HCPCS/CPT code updates. Also train all staff on the False Claims Act and what can be considered a false claim. Include information on how to report concerns and suspected violations, and that prompt reporting is mandatory. Document that the trainings occurred and place in each employee’s education file.
- Periodically audit to ensure that claims are billed accurately. Also periodically audit staff understanding to ensure that they are aware of what should be done if they suspect a false claim has occurred, whether intentionally or unintentionally. Conduct audits of documentation and billing routinely to prevent and detect errors before they progress to a false claim.
