Therapy Services

20.5 - Therapy Services (Rev. 2573, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13) Therapy services are edited as inclusions, rather than exclusions, to consolidated billing. Physical therapy, speech-language pathology services, and occupational therapy are bundled into the SNF’s global per diem payment for a resident’s covered Part A stay. They are also subject to the SNF “Part B” consolidated billing requirement (for services furnished to SNF residents during noncovered stays) and must be billed by the SNF alone for its Part B residents on a 22x type of bill. As noted in section 10.3 of this chapter, therapy services furnished to SNF residents remain subject to consolidated billing even when performed by a type of practitioner, such as a physician, whose services would otherwise be excluded (see section 1888(e)(2)(A)(ii) of the Social Security Act and the regulations at 42 CFR 411.15(p)(1)(i)). Further, while most services either clearly fall within the category of therapy or clearly fall outside of it, there are a few services (such as certain debridement codes) which, based on the specific type of practitioner involved, are sometimes considered “therapy” services and other times not. However, because the consolidated billing provision focuses on the nature of the therapy service itself (rather than the type of practitioner who happens to be performing it), these “sometimes therapy” codes are always considered therapy services in the specific context of SNF consolidated billing. This means that a practitioner who furnishes such a service to an SNF resident must always look to the SNF itself (rather than to Part B) for payment. SNF residents that fall below a Medicare skilled level of care may be moved out of the SNF or certified distinct part unit (DPU) to the Medicare non-certified area of the facility. In doing so, the beneficiary is no longer subject to the SNF consolidated billing rule and therapy services may be billed directly to Medicare by the provider rendering the service or if billed by the SNF should be submitted on a 23x type of bill. If the entire facility qualifies as a Medicare-certified SNF, all Part B therapies must continue to be billed by the SNF on a 22x type of bill. The CWF SNF CB therapy edit will be bypassed for 22x bill types that contain therapy services when those line item dates of service fall within a non-covered period reported on an inpatient 21x bill type. For additional instructions, see Chapter 7, SNF Part B Billing, section 10.1. In transmittals for A/B MAC (A) billing providing the annual update list of HCPCS codes affected by SNF consolidated billing, such services are referred to as “Major Category V” of SNF consolidated billing. See section 10.1 above for the link to where transmittals providing current lists of HCPCS codes used for Major Category V can be found.