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2017 Part B Mac Update

2017 Annual Part B MAC Update

The SNF consolidated billing files reflect new codes that have been developed for 2017 and codes that have been discontinued for 2017. In addition, the files reflect any additions and deletions to categories of services excluded from consolidated billing. These files are effective for claims with dates of service on or after 1/01/2017 unless otherwise noted.

Note:  There is a new Healthcare Common Procedure Coding System (HCPCS) code (G9678 – the Oncology Care Model (OCM) Monthly Enhanced Oncology Services (MEOS) that will be back dated to July 1, 2016. The affected HCPCS code for practitioner billing will be added to File 1. If you have claims with dates of service from July 1 through December 31, 2016, that have been erroneously denied, you should contact your Medicare Administrative Contractor to have the claims re-opened and re-processed.

File 1 - Part A Stay - Physician Services (see file below)

Services represented by these codes are not subject to skilled nursing facility (SNF) consolidated billing for Medicare beneficiaries in a SNF Part A covered stay. They should be submitted to the Part B MAC or Durable Medical Equipment MAC, as appropriate, for payment consideration.

The following codes when billed globally, or as a separate technical component or professional component billed with a TC or 26 modifier, are excluded from consolidated billing and may be paid separately by the Part B MAC: 78804, 79200, 79300, 79403, and 79440. These codes therefore appear on both File 1 and File 2.

Please be aware that certain codes were overlooked when the 2017 and 2018 annual CWF coding files were created. Until the codes can be added to the processing files on October 1, 2018, providers should contact their MACs to have incorrectly denied claims reopened and reprocessed. Should they have received payment from the Skilled Nursing Facility (SNF), they must return that payment to the SNF before requesting payment from CMS.

File 2 - Part A Stay - Professional Components of Services to be Submitted with a 26 Modifier (see file below)

Note: The professional component of the services represented by these codes are not subject to skilled nursing facility (SNF) consolidated billing and will be considered for payment by the Part B MAC for Medicare beneficiaries in a SNF Part A stay. These codes must be submitted with a modifier of 26 to indicate "professional component".

File 3 - Part A Stay - Ambulance (see file below)

Note: These are ambulance codes that will always be denied by the Part B MAC for Medicare beneficiaries in a skilled nursing facility Part A covered stay when submitted with an NN modifier. Effective 10/4/04, per Transmittal 163, these ambulance codes will also be denied when submitted with modifiers ND or DN.

File 4 - Part B Stay Only - Therapy Services (see file below)

Note: Services represented by these codes are the only services subject to skilled nursing facility (SNF) consolidated billing for Medicare beneficiaries in a SNF Part B stay. The file includes codes for physical, occupational and speech therapy. The Part B MAC will always deny these codes for Medicare beneficiaries in a SNF Part B stay. Therapy services must be provided and billed under arrangement with the SNF.