Edit for Clinical Social Workers (CSWs)

110.2.5 - Edit for Clinical Social Workers (CSWs) (Rev. 3481, Issued: 03-18-16. Effective: 06-20-16, Implementation: 06-20-16) Per the Balanced Budget Act, services provided by CSWs to beneficiaries in a Part A SNF stay may not be billed separately to the A/B MAC (B). Payment for these services is included in the prospective payment rate paid to the SNF by the A/B MAC (A). Though the policy was in effect since April 1, 2001, there were no corresponding edits. With the April 2003 release, CWF implemented a new SNF consolidated billing edit to prevent payment to CSWs for services rendered to beneficiaries in a Part A SNF stay. Effective April 1, 2003, CWF established the new edit 7269 for services rendered to these beneficiaries with dates of service on or after April 1, 2001, for claims received on or after April 1, 2003. Once CWF determines that a beneficiary is in a Part A stay, prior to applying the edits that review procedure codes to determine if payment should be allowed, CWF will review the performing provider type of the submitting entity. If the performing provider type is 80, CWF will reject the claim to the A/B MAC (B) or return an unsolicited response with new error code 7269. The A/B MAC (B) will then take the same adjustment and recovery action as for other rejects and unsolicited responses. When A/B MACs (B) receive the new reject code, they must deny the claim and use the following RA and MSN messages. The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three. Group Code: CO CARC: 96 RARC: N121 MSN: 13.10 Effective for claims with dates of service on or after April 1, 2001, CWF implemented revisions on January 2, 2008 to bypass edit 7269 when a claim with a date of service on or after April 1, 2001 is submitted and the date of service is within the From/Thru dates with an occurrence Span code date of 74, 76, 77, 79, or M1 reported on a SNF inpatient claim 21x in history or the date of service is greater than the occurrence date on a SNF inpatient claim 21x in history with an occurrence code date of A3, B3, or C3. This will allow for services to be separately payable outside of SNF consolidated billing during non-covered periods in the SNF.