Consolidated Billing Questions Answered

Do you have questions about items included in Consolidated Billing? Refer to our Consolidated Billing page and utilize our Consolidated Billing tool to determine if a specific Healthcare Common Procedure Coding System (HCPCS) code is considered under consolidated billing.

Part A Covered Stay

Medicare does not pay for individual items furnished during an inpatient Part A stay. These items are paid to hospitals and Skilled Nursing Facilities (SNFs) through the Inpatient Prospective Payment System (IPPS) under Medicare Part A. The facility must furnish all inpatient services and DMEPOS items during the stay or arrange for a supplier to furnish them. If necessary, the supplier will work out a payment arrangement with the facility as they are the ones receiving reimbursement from Medicare for items provided.

It is the supplier's responsibility to check with the facility to determine if their beneficiary is a resident in a covered Part A stay. If so, all items must be billed to Medicare by the SNF except for certain excluded items. A complete list of these excluded items (listed by HCPCS) may be found on the CMS SNF Consolidated Billing webpage >  [YEAR] Part B MAC Update > Downloads > File 1 – Part A Stay (Physician services). If a HCPCS code appears on this list, it may be billed to the DME MAC for reimbursement, even if the beneficiary is in a covered Part A SNF stay.

Not in a Part A Stay

Coverage consideration for DMEPOS items in a Skilled Nursing Facility (31) or a Nursing Facility (32) for beneficiaries not in a Part A covered stay is limited to the following:

  • Prosthetics, orthotics, and related supplies
  • Urinary incontinence supplies
  • Ostomy supplies
  • Surgical dressings
  • Oral anticancer drugs
  • Oral antiemetic drugs
  • Therapeutic shoes for diabetics
  • Parenteral/enteral nutrition (including E0776BA, the IV pole used to administer parenteral/enteral nutrition)
  • ESRD - dialysis supplies only
  • Immunosuppressive drugs

Home Health Episode

The Balanced Budget Act of 1997 requires consolidated billing of all home health services while a beneficiary is under a home health plan of care authorized by a physician. Consequently, billing for all such items and services will be made to a single home health agency (HHA) overseeing that plan.

Types of services that are subject to the Home Health Prospective Payment System (PPS) include routine and non-routine medical supplies.

When a beneficiary is in a 60-day home health episode, these items are included in the PPS episode payment. HHAs must bill for all supplies provided during the 60-day episode including those not related to the plan of care because of the consolidated billing requirements. Items such as urological supplies, ostomy supplies, and surgical dressings are included in Home Health Consolidated billing and cannot be separately billed to the DME MAC. If a HCPCS code appears on this list, it may not be billed to the DME MAC when the beneficiary is in a home health episode.

Eligibility

Suppliers are encouraged to check beneficiary eligibility either through the Noridian Medicare Portal (NMP) or the Interactive Voice Response (IVR).

 

            Last Updated Mon, 08 Nov 2021 18:11:06 +0000