Medicare SNF Coverage Guidelines Under PPS

10.2 - Medicare SNF Coverage Guidelines Under PPS (Rev. 12283, Issued:10-05-23, Effective:01-08-24, Implementation:01-08-24) Under SNF PPS, covered SNF services include post-hospital SNF services for which benefits are provided under Part A (the hospital insurance program) and all items and services which, prior to July 1, 1998, had been paid under Part B (the supplementary medical insurance program) but furnished to SNF residents during a Part A covered stay other than the following: • Physician services, physician assistant services, nurse practitioner and clinical nurse specialist services, certified mid-wife services, qualified psychologist services, marriage and family therapist services, mental health counselor services, certified registered nurse anesthetist services, certain dialysis-related services, erythropoietin (EPO) for certain dialysis patients, hospice care related to a terminal condition, ambulance trips that convey a beneficiary to the SNF for admission or from the SNF following discharge, ambulance transportation related to dialysis services, certain services involving chemotherapy and its administration, radioisotope services, certain customized prosthetic devices, certain blood clotting factors and, for services furnished during 1998 only, the transportation costs of electrocardiogram equipment for electrocardiogram test services. Certain additional outpatient hospital services (along with ambulance transportation that conveys a beneficiary to a hospital or CAH to receive the additional services) are excluded from coverage under SNF PPS and are billed separately. The additional services are: • Cardiac catheterization services; • Computerized axial tomography (CT scans); • Magnetic resonance imaging (MRIs); • Radiation therapy; • Ambulatory surgery involving the use of a hospital operating room; • Emergency services; • Angiography services; and • Lymphatic and venous procedures. The CMS identifies the above services using HCPCS codes that are periodically updated. The CMS publishes the HCPCS coding changes in each year via a Recurring Update Notification. Other updates for the remaining quarters of the FY will occur as needed due to the creation of new temporary codes representing services included in SNF PPS prior to the next annual update. To view the online code list of exclusions from consolidated billing (CB, the SNF “bundling” requirement), go to the CB Overview page at www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html and proceed as follows: • In the left-hand column of the CB Overview page, scroll down to the applicable Part A MAC (Medicare Administrative Contractor) Update to access the list of excluded codes that are billable by institutional providers (similar information is available for practitioners and other noninstitutional suppliers on the applicable Part B MAC Update). To view the most current update (the one that displays the most recent set of revisions to the code list), click on the “Part A MAC Update” link for the current year. This directs to a page that lists by Major Category (indicating the type of service) the specific changes in coding for this year. • To see a complete list of the CB exclusions (along with the ambulatory surgery and Part B therapy inclusions), scroll down the Part A MAC Update page to the “Downloads” section. Then, click on the link to the zipped file entitled “Annual SNF Consolidated Billing HCPCS Updates” for the current year. Once this file is unzipped, the complete exclusion list can be selected in either Microsoft Excel or Text formats, and can then be searched for individual codes. • For a general explanation of the types of services encompassed by each of the Major Categories, scroll down the Part A MAC Update page to the “Downloads” section, and click on the link to the “General Explanation of the Major Categories.” (For example, Major Category III.A lists the excluded chemotherapy codes, and Major Category III.B lists the excluded chemotherapy administration codes.) For further information on the SNF CB provision, see Pub. 100-04, Medicare Claims Processing Manual, chapter 6, sections 10 through 20.6.