Other Services Excluded from SNF PPS and Consolidated Billing

20.3 - Other Services Excluded from SNF PPS and Consolidated Billing (Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21) The following services may be billed separately under Part B by the rendering provider, supplier, or practitioner (other than the SNF that receives the Part A PPS payment) and paid to the entity that furnished the service. These services may be provided by any Medicare provider licensed to provide them, other than the SNF that receives the Part A PPS payment, and are excluded from Part A PPS payment and the requirement for consolidated billing, and are referred to as “Major Category III” for consolidated billing edits applied to claims submitted to A/B MACs (A). • A medically necessary ambulance trip (other than a transfer to another SNF) that transports a beneficiary to the SNF for the initial admission or from the SNF following a final discharge, or that occurs pursuant to the offsite provision of Part B dialysis services (see section 20.3.1 for additional situations involving ambulance transportation); • Certain chemotherapy (that is, anti-cancer) drugs. The chemotherapy exclusion applies solely to the particular chemotherapy codes designated under Major Category III.A of the SNF website’s A/B MAC (A) Annual Update. These same codes also appear on the list of exclusions in File 1 of the SNF website’s A/B MAC (B) Annual Update (though not displayed as a separate subcategory). The excluded chemotherapy codes serve to identify those high-intensity chemotherapy drugs that are not typically administered in a SNF, are exceptionally expensive, or require special staff expertise to administer. By contrast, chemotherapy drugs that are relatively inexpensive and are administered routinely in SNFs do not qualify for this exclusion and, thus, remain subject to SNF CB. Further, this exclusion would not encompass any related items that, while commonly furnished in conjunction with chemotherapy, are not themselves inherently chemotherapeutic in nature (that is, they specifically address the side effects of the chemotherapy rather than actively fighting the cancer itself). Examples of such chemotherapy-related drugs would include anti-emetics (anti-nausea drugs), as well as drugs that function as an adjunct to an anti-emetic, such as an anti-anxiety drug that helps to relieve anticipatory nausea. Even when furnished in conjunction with a chemotherapy drug that is itself excluded (and, thus, separately payable under Part B), these related drugs would remain subject to SNF CB. Similarly, if a drug designated by one of the excluded chemotherapy codes is prescribed for a use that is not actually associated with fighting cancer, it would no longer be considered an excluded “chemotherapy” drug in such an instance, because it is not being used for a chemotherapeutic purpose within the meaning of this exclusion. • Certain chemotherapy administration services. The chemotherapy administration codes are included in SNF PPS payment for beneficiaries in a Part A stay when performed alone or with other surgery, but are excluded if they occur with the same line item date of service as an excluded chemotherapy agent. A chemotherapy agent must also be billed when billing these services, and physician orders must exist to support the provision of chemotherapy; • Certain radioisotope services; • Certain customized prosthetic devices (see §10); • Effective for items and services furnished on or after October 1, 2021, certain blood clotting factors indicated for the treatment of hemophilia and other bleeding disorders; • The transportation costs of electrocardiogram equipment (HCPCS code R0076), but only with respect to those for electrocardiogram test services furnished during 1998; and • All services provided to risk-based MCO beneficiaries. These beneficiaries may be identified with a label attached to their Medicare card and/or a separate health insurance card from an MCO indicating all services must be obtained or arranged through the MCO (as noted previously in §10, consolidated billing applies only to Medicare fee-for- service beneficiaries). The HCPCS code ranges for chemotherapy, chemotherapy administration, radioisotopes, customized prosthetic devices, and blood clotting factors are set in statute. The statute also gives the Secretary authority to make modifications in the particular codes that are designated for exclusion within each of these service categories. See §10.1 above for the link to where transmittals providing current lists of HCPCS codes used for Major Category III SNF consolidated billing editing for A/B MACs (A) can be found.