Skilled Nursing Facility (SNF) Consolidated Billing (CB) Matrix

The following Matrix is designed to help in determining if a code is part of SNF CB and who it should be billed to. The CMS website contains SNF Consolidated Billing update files. A "Y" indicates it is found in that file; "N" indicates it is not found.

Table for HCPCS 0001T-0021T, 0024T-0026T, or 10021-69990

Part A File Part B File 1 Part B File 2 Where services should be billed
Y N N Included in SNF CB, all charges billed to SNF
N N N Excluded from SNF CB, can be billed to Part A
N Y N Excluded from SNF CB, can be billed to Part A or Part B
N N Y Excluded from SNF CB, professional portion billed to Part B with modifier 26. technical portion billed to Part A
Y Y N Excluded from SNF CB, can be billed to Part B
Y N Y Professional portion excluded from SNF CB, can be billed to Part B with 26 modifier. Technical portion included, billed to SNF.

 

Special Note: HCPCS with the same line item date of services as an excluded service above are also excluded and can be billed to Part A.

Table for All other HCPCS not listed Above

Part A File Part B File 1 Part B File 2 Where services should be billed
N N N Included in SNF CB, all charges billed to SNF
Y N N Excluded from SNF CB, can be billed to Part A
Y Y N Excluded from SNF CB, can be billed to Part A or Part B
Y N Y Excluded from SNF CB, professional portion billed to Part B with modifier 26. technical portion billed to Part A
N Y N Excluded from SNF CB, can be billed to Part B
N N Y Professional portion excluded from SNF CB, can be billed to Part B with 26 modifier. Technical portion included, billed to SNF.

 

Special Circumstances

The CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual (MCPM) contains exceptions and other notable circumstances.

Type of Service Reference Description
Ambulance Services CMS IOM, Publication 100-04, MCPM, Chapter 6, Section 20.3.1 Codes A0425-A0436 and A0999 will always be denied by Part B for Medicare beneficiaries in a skilled nursing facility Part A covered stay when submitted with an NN modifier. Effective 10/04/04, these codes will also be denied when submitted with modifiers ND or DN.
Chemotherapy Services
(Admin codes 96401-96549)
CMS IOM, Publication 100-04, MCPM, Chapter 6, Section 20.3 Chemotherapy Administration codes listed in the Part A file with an asterisk (*) are included in SNF CB, but when billed with a Chemotherapy agent that is excluded, the Chemotherapy Administration code is also excluded.
Emergency Services CMS IOM, Publication 100-04, MCPM, Chapter 6, Section 20.1.2.2 Any services provided on the same DOS as the 45X revenue code, or that are related to the E&M visit on the following date of service are also excluded from CB and can be billed to Part A with an ET modifier.
Facility Charge for Evaluation and Management (E&M) CMS IOM, Publication 100-04, MCPM, Chapter 6, Section 20.1.1.2 E&M codes 99201-99245 and G0463 may be billed to Part A on revenue code 0510 for facility fee reimbursement only
Facility fees for an Ambulatory Surgical Centers (ASC) CMS IOM, Publication 100-04, MCPM, Chapter 6, Sections 20.1.2 and 110.2.7 Facility services provided by a freestanding non-hospital ASC are included under the SNF CB provisions and are billed to the SNF. ASCs are Part B only providers that would usually bill on 1500 forms.
Professional Services in a CAH Method II CMS IOM, Publication 100-04, MCPM, Chapter 4 Any services listed as being billed to Part B with a 26 modifier above can be billed by a CAH Method II when the physician has reassigned billing to the CAH. Would be billed on the 85X TOB on revenue codes 96X, 97X, or 98X without the 26 modifier.
Technical component (TC) of radiology services CMS IOM, Publication 100-04, MCPM Chapter 13, Section 20.2.1 Technical component (TC) of radiology services furnished to SNF inpatients during a Part A covered stay. These should be billed to the SNF and payment is included in SNF PPS rate. Radiology services furnished to outpatients of SNFs may be billed by the supplier performing the service to Part B, or by the SNF under arrangements with the Part B supplier.
Therapy and "Sometimes" Therapy Services CMS IOM, Publication 100-04, MCPM, Chapter 6, Section 20.5 Therapy services billed with revenue codes 42X, 43X and 44X are included in SNF CB for residents in a Part A stay (TOB 21X) and must be billed by the SNF alone for its Part B residents (TOB 22X) and non-residents (TOB 23X). Refer to File 4 - Part B Stay Only - Therapy Services and the annual therapy code list.
Vaccines (pneumococcal and influenza, Hep B) and screening mammography CMS IOM, Publication 100-04, MCPM, Chapter 18, Section 10.2.2 A SNF bills Part A on bill type 22X using the discharge date or the date that benefits exhausted. MCPM Ch 6, sect. 20.4

 

Last Updated Fri, 06 Mar 2020 12:18:47 +0000