Description
Services provided by a freestanding non-hospital ASC (Ambulatory Surgery Center) are included under the SNF Consolidated Billing Provisions. Certain services are not payable because they are included in SNF Consolidated Billing. Codes found in the SNF Consolidated Billing – Part A MAC Updates are overpayments and will be recovered
Affected Code(s)
Annual SNF Consolidated Billing Part A MAC Codes
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
3. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, §1815(a)- Payment to Providers of Services
4. 42 CFR §405.929- Post-Payment Review
5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
6. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
7. 42 CFR §405.986- Good Cause for Reopening
8. 42 CFR §424.5(a)(6)- Sufficient Information
9. 42 CFR § 424.32(a)(1) - Basic requirements for all claims
10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
11. Medicare Claims Processing Manual, Chapter 6- SNF Inpatient Part A Billing and SNF Consolidated Billing, §20.1.2- Other Excluded Services Beyond the Scope of a SNF Part A Benefit
12. Medicare Claims Processing Manual, Chapter 6- SNF Inpatient Part A Billing and SNF Consolidated Billing, §110.2.7- Edit to Prevent Payment of Facility Fees for Services Billed by an Ambulatory Surgical Center (ASC) when Rendered to a Beneficiary in a Part A Stay
13. SNF Consolidated Billing – Annual Updates for Part A MAC https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling
14. General Explanation of the Major Categories for Skilled Nursing Facility (SNF) Consolidated Billing- General Explanation of the Major Categories for Skilled Nursing Facility (SNF) Consolidated Billing (cms.gov)
15. HCPCS Level II Codebook
16. AMA CPT Codebook