Consolidated Billing

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Consolidated Billing Chart

Suppliers are encouraged to check beneficiary’s eligibility through the Noridian Medicare Portal (NMP) to verify the beneficiary’s status. Are they in a Part A Skilled Nursing Facility (SNF) stay, in a SNF after Part A stay has ended, home health episode, or under hospice coverage? By checking eligibility, the supplier can make an informed decision on whether to provide services or not, as some items may be covered under the Consolidated Billing requirements.

Suppliers are encouraged to utilize the Consolidated Billing Tool on the Noridian Medicare website to assist them in determining whether a Healthcare Common Procedure Coding System (HCPCS) code is considered under consolidated billing.

Beneficiary’s Status Definition Covered or Non-covered
SNF - During Part A inpatient Stay Medicare does not pay for individual items furnished during an inpatient stay. The facility must furnish all inpatient services and DMEPOS items during the stay except items on SNF Excluded list SNF excluded codes that are allowed during a Part A inpatient stay and may be billed to the DME MAC. This listing is updated yearly for the items that can be billed to the DME MAC during a Part A stay. No other items are allowed to be billed to the DME MAC.
SNF - After Part A stay has ended Coverage consideration for DMEPOS items in a SNF place of service (POS 31) or a nursing facility (POS 32) for beneficiaries not in a Part A covered stay is limited to the items listed in column to the right. If items do not fall within these categories, the beneficiary will be responsible for payment. Covered
  • 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)
  • End Stage Renal Disease (ESRD) - dialysis supplies only
  • Immunosuppressive drugs
  • Lymphedema compression treatment Items
Home Health Services - Beneficiary is in a 60-day home health episode All home health services while a beneficiary is under a home health plan of care authorized by a physician are not payable by the DME MAC. Billing for all HCPCS codes on the Home Health Consolidated Billing Master Code List will be made to a single home health agency (HHA) overseeing that plan. These items are included in the Prospective Payment System (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. If a HCPCS code appears on the Home Health Consolidated Billing Master Code List it may NOT be billed to the DME MAC when beneficiary is in a home health episode. 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.
Hospice When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of his/her terminal illness. During any period in which the hospice benefit election is in force, all items related to treatment and management of his/her terminal illness are paid by the intermediary and should not be billed to the DME MAC
  • Any covered Medicare services not related to the treatment of the terminal hospice condition, and which are furnished during a hospice election period, may be billed to the DME MAC for payment.
  • Services should be coded with the GW modifier ("service not related to the hospice patient's terminal condition").

Improper Inpatient Payments

Medicare does not pay for individual items furnished during an inpatient stay. These items are paid to the Acute Care Hospitals, Long Term Care Facilities, Inpatient Psychiatric Facilities 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. For additional guidance, access the "CMS Medicare DMEPOS Improper Inpatient Payments Fact Sheet" within the "Educational Resources" section of this page.

SNF Residents

Section 4432(b) of the Balanced Budget Act (BBA) requires CB for the SNF. The CB requirement essentially confers on the SNF the Medicare billing responsibility for the entire package of care that its residents receive, except for a limited number of specifically excluded services.

  • For services and supplies furnished to a SNF resident covered under the Part A benefit, SNFs are not able to unbundle services to an outside provider of services or supplies that can then submit a separate bill directly to Medicare. Instead, the SNF must furnish the services or supplies either directly or under an arrangement with an outside provider. The SNF, rather than the provider of the service or supplies, bills Medicare. Medicare does not pay amounts that are due to a provider of the services or supplies to any other entity under assignment, power of attorney, or any other direct payment arrangement. (See 42 CFR 424.73)
  • As a result, the outside supplier of the service or supplies must look to the SNF, rather than to the beneficiary or Medicare, for payment. The SNF may collect any applicable deductible or coinsurance from the beneficiary. Most covered services and supplies billed by the SNF, including those furnished under arrangement with an outside provider, for a resident of a SNF in a covered Part A stay are included in the SNF's bill to the Fiscal Intermediary (FI).
  • It is the supplier's responsibility to check with the facility to see if their beneficiary is a resident in a covered Part A stay. If so, all services must be billed to Medicare by the SNF except for certain excluded items. If items are provided to a beneficiary that is in a Part A SNF stay and discharge has not been completed and billed, it is the supplier's responsibility to work with that facility to resolve.
  • A complete list of these excluded items (listed by HCPCS may be found on the CMS SNF Consolidated Billing webpage. 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.
    • Note: To access the list, click on the link above, select the appropriate "Part B MAC Update" (whichever year in which the service took place, click on the year), and open the ZIP file found in the Downloads section. (File 1 Part A Stay Physician services).

Note: Part A suppliers have one year from the initial date of service to close and bill their claims.

SNF CB - Capped Rental DME

Medicare pays for DME when it is medically necessary for use in a beneficiary's home and is never covered under a part A stay.

For capped rental items of DME where the supplier submits a monthly bill, the date of delivery on the first claim must be the "from" or anniversary date on all subsequent claims for the item.

The DME benefit is only meant for items a beneficiary is using in his or her home. For a beneficiary in a Part A covered stay, a SNF is not defined as a beneficiary's home. Medicare does not make separate payment for DME when a beneficiary is in a SNF. The SNF is expected to provide all medically necessary Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) during a beneficiary's covered Part A Stay with a few exceptions as noted above.

However, in accordance with DMEPOS payment policy, Medicare will make a separate payment for a full month of rental for DME items, provided the beneficiary was in the home on the "from" date or anniversary date defined above. Medicare will make payment for the entire month, even if the "from" date is the date of discharge from the SNF.

If a beneficiary using DME is in a covered Part A stay in a SNF for a full month, Medicare will not make payment for the DME for that month.

If the beneficiary is in a Part A covered stay, on the rental anniversary date, but not for the entire month, the discharge date becomes the new anniversary date for subsequent claims.

  • In this situation, submit a new claim using the date of discharge as the "from" date.
  • Note in the NTE segment/line note (narrative) that the beneficiary was in a SNF, resulting in the need to establish a new anniversary date. e.g., Bene in SNF, new ANND 12/25/2021
    • Loop 2400 (line note), segment NTE02 (NTE01=ADD) of the ANSI X12N, version 5010A1 professional electronic claim format or on Item 19 of the paper claim form.

DMEPOS Claims During Inpatient Stay

  • The DMEPOS benefit is meant only for items a beneficiary is using in his or her home. For a beneficiary in a Part A inpatient stay, an institution is not defined as a beneficiary's home for DMEPOS. Medicare does not make separate payment for DMEPOS when a beneficiary is in the institution. The institution is expected to provide all medically necessary DMEPOS during a beneficiary's covered Part A stay.
  • However, there is an exception to the general rule above. In accordance with DMEPOS payment policy, Medicare will make a separate payment for a full month for DMEPOS items, provided the beneficiary was in the home on the "from" date or anniversary date defined below.
  • For DME items where the supplier submits a monthly bill, the date of delivery ("from" date) on the first claim must be the "from" or anniversary date on all subsequent claims for the item. For example, if the first claim for a wheelchair is dated September 15, all subsequent bills must be dated for the 15th of the following months (October 15, November 15, etc.).
  • If a beneficiary using DME is at home on the "from" date or anniversary date, Medicare will make payment for the item for the entire month, even if the "from" date is the date of discharge from the institution.
  • If a beneficiary using DME is in a covered Part A stay for a full month, Medicare will not make payment for the item for that month.
  • When the "from" date on the DMEPOS claim falls within an inpatient stay and the beneficiary returns home within the same calendar month, the supplier must submit a new claim on the date of discharge from the institutional provider and the date of discharge will become the "from" (anniversary) date for all subsequent claims.
  • Suppliers should note in the NTE segment/line note (narrative) that the beneficiary was in a SNF, resulting in the need to establish a new anniversary date. e.g., Bene in SNF, new ANND 12/25/2021
    • Loop 2400 (line note), segment NTE02 (NTE01=ADD) of the ANSI X12N, version 5010A1 professional electronic claim format or on Item 19 of the paper claim form.
Example Scenario Medicare Processing
1 A beneficiary rents a wheelchair beginning on January 1. The DME MAC determines the wheelchair is medically necessary and the beneficiary meets all coverage criteria, and so begins to make payment on the wheelchair. The beneficiary enters a hospital on February 15 and is discharged on April 5. In this example, Medicare will make payment for the entire month of February, because the patient was in the home for part of the month. However, the DME MAC will deny the claim for March, because the patient was in a covered hospital stay for the entire month.

Because the anniversary date ("from" date) of the monthly bill was April 1, and the patient was still in the covered hospital stay on that date, the DME supplier must not submit another claim until April 5 (the date of discharge). April 5 becomes the new anniversary date ("from" date) for billing purposes, so the supplier would now bill on the 5th of the month rather than the 1st of the month for the remainder of the capped rental period.
2 A beneficiary rents a hospital bed on January 1. On February 28, the beneficiary enters a hospital and is discharged on March 15. In this example, the DME MAC would deny a claim dated March 1. The supplier would submit a new claim dated March 15, which would then become the anniversary date for billing purposes.
3 A beneficiary rents a hospital bed beginning on January 1. On March 15, the beneficiary enters a hospital and is discharged on March 25. In this example, the DME MAC will make payment for the entire month of March.
4
A beneficiary rents a wheelchair beginning December 15. On January 1, the beneficiary enters a hospital and is discharged on January 31.		 In this example, the DME MAC will deny the claim dated January 15. The supplier would submit a new claim dated January 31, which would then become the anniversary date for billing purposes. The February claim would be dated February 28 because there is no 31st day in February

DMEPOS Claims After Discharge from Inpatient Stay

In order to avoid denials for inpatient stays, suppliers are encouraged to check the beneficiary's eligibility through the Noridian Medicare Portal (NMP) to verify the beneficiary's discharge status code.

On the NMP under the eligibility tab is Hospital/SNF. The discharge status code will determine if the beneficiary is eligible to receive DMEPOS items as some items may be covered under the Consolidated Billing requirements. Suppliers will need to "click here for discharge status" under the discharge status column for the code to display. It is critical for suppliers to ensure that the discharge status code indicates that the beneficiary has been discharged to home in order to be eligible for coverage.

Suppliers are encouraged to utilize the Consolidated Billing Tool to assist in determining whether a Healthcare Common Procedure Coding System (HCPCS) code is considered under consolidated billing.

Is the beneficiary in a Part A covered Skilled Nursing Facility (SNF) stay or in a SNF after the Part A stay has ended, or have they been discharged to home?

Inpatient SNF Hospital Summary on the NMP

Each table will display a summary of the Earliest and Latest Billing Dates with the following information:

Note: If the patient discharge status code does not reference that the beneficiary has been discharged to home, suppliers may need to work directly with the facility to ensure the discharge did occur and that the medical record is updated accordingly.

SNF Residents - Not in a Covered Part A Stay

Coverage consideration for DMEPOS items in a Skilled Nursing Facility (POS 31) or a Nursing Facility (POS 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
  • Lymphedema Compression Treatment Items

Note: This list does not apply to situations in which the beneficiary is in a Part A covered SNF stay.

Home Health PPS

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.

The law states that payment will be made to the primary HHA whether or not the item or service was furnished by the agency, by others under arrangement to the primary agency, or when any other contracting or consulting arrangements existed with the primary agency, or "otherwise." Payment for all items is scheduled in the home health PPS episode payment that the primary HHA receives.

Types of services that are subject to the Home Health PPS include:

  • Skilled nursing care
  • Home health aide services
  • Physical therapy
  • Speech-language pathology
  • Occupational therapy
  • Medical social services
  • Routine and non-routine medical supplies
  • Medical services provided by an intern or resident-in-training of a hospital, under an approved teaching program of the hospital, in the case of a HHA that is affiliated or under common control with that hospital; and
  • Care for homebound patients involving equipment too cumbersome to take to the home.

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.

The "Home Health Consolidated Billing Master Code List" is located on the CMS Home Health PPS Coding and Billing webpage.

  • 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.

Suppliers are encouraged to check eligibility through NMP for these 60-day Home Health episodes. When checking the Home Health Episode History in NMP:

  • Payer name and ID, provider number, episode start, and end date and earliest and latest billing dates will display if an episode exits within the specific date range entered.
  • If a specific date of service is in question, enter those dates or the beneficiary's eligibility will display for the current date.

DMEPOS and Hospice

When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of his/her terminal illness. During any period in which the hospice benefit election is in force. All items related to the treatment and management of his/her terminal illness are paid by the intermediary.

  • Any covered Medicare services not related to the treatment of the terminal hospice condition and which are furnished during a hospice election period, may be billed to the DME MAC for payment.
  • Services should be coded with the GW modifier ("service not related to the hospice patient's terminal condition"). DME MACs process services coded with the GW modifier in the normal manner for coverage and payment determinations.

Suppliers are encouraged to check eligibility through NMP for hospice coverage. When checking for hospice coverage in the NMP:

  • Episode effective date, termination date and the provider number will display.
  • If a specific date of service is in question, enter those dates or the beneficiary's eligibility will display for the current date.

Resources

Last Updated Oct 04 , 2024