Job Aid B: Determining Professional Consolidated Billing Services

Job Aid B is an interactive decision tree with a series of questions that help you determine if the professional service you provide falls under SNF Consolidated Billing services. The services are broken down into physician, professional and ambulance services. Your answers to a series of questions determine which Part B file you use to see if the code is excluded or included in CB.

Scenario 1:

If the SNF stay is covered by Part A, is it an institutional or professional service? If it’s institutional, refer to Job Aid A. If it’s professional, is it a physician’s service? If yes, physicians, NPP professional services and suppliers, other than ambulance, are excluded from SNF CB. In that case, you determine the appropriate CPT or HCPCS code. Go to the SNF Consolidated Billing webpage and choose the Part B MAC Update link, then choose File 1 – Part A Stay – Physician Services for the year you delivered the service. Check that file for the applicable CPT or HCPCS code, and if it’s on the list, we exclude the service, and you bill the MAC directly.

Scenario 2:

If the SNF stay is covered by Part A and is the professional services component of a diagnostic test, determine the appropriate CPT or HCPCS code. Go to the SNF Consolidated Billing webpage, Part B MAC Update link, then look up the CPT or HCPCS code in File 2 – Part A Stay – Professional Components of Services Submitted with the 26 modifier for the year you delivered the service. If the CPT or HCPCS code is on the list, we exclude the service, and you bill the MAC with a -26 modifier. The practitioner must look to the SNF for the technical component payment.

Scenario 3:

If the SNF stay is covered by Part A and is an ambulance service, there are some specific situations where you bill transportation separately. Ambulance services aren’t categorically excluded from Part A SNF CB. Determine the appropriate CPT and HCPCS code, then go to the SNF Consolidated Billing webpage, Part B MAC Update link then look it up in File 3 – Part A Stay – Ambulance. If you’re using the -NN, -DN, or -ND modifier, the service is included in CB, and you look to the SNF for payment. If you’re not using those modifiers, the services are excluded from CB, and you bill the MAC.

Scenario 4:

If the SNF stay isn’t covered by Part A and is a PT, OT, or SLP service, these are the only services subject to SNF CB for Medicare patients in a SNF Part B stay. Determine the appropriate CPT or HCPCS code, go to the SNF Consolidated Billing webpage, Part B MAC Update link for the year you delivered the service, then select File 4 – Part B Stay Only – Therapy Services. Search for the applicable CPT or HCPCS code. If the code appears, it’s an included service and you look to the SNF for payment.

If the services aren’t PT, OT, or SLP services, we don’t include those services in CB, and you bill the MAC directly.