Corporate Compliance

Note from Hugh

Medicare Insider, June 26, 2007

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As discussed below, last week, CMS issued a MLN Matters article "clarifying" a transmittal that CMS has previously issued on certain changes to the codes subject to skilled nursing facility (SNF) consolidated billing. At first blush, hospitals may think that this is a "SNF issue" that doesn't affect hospital billing. However, the SNF consolidated billing requirements can affect hospitals because if a hospital furnishes services to a SNF resident that are subject to SNF consolidated billing, the hospital may not bill Medicare for the services. Rather, the hospital must bill the SNF.

Both last week's MLN Matters article and the preceding transmittal announced that the diagnostic mammography codes (CPT codes 77055 and 77056) are no longer included as "Major Category IV" codes in the SNF consolidated billing files. Major Category IV is intended to list "preventative and screening services" that are not included in the SNF Prospective Payment System but are covered under Medicare Part B and must be billed by the SNF for patients in a SNF Part A stay. Presumably CMS made this change in recognition of the fact that CPT codes 77055 and 77056 represent diagnostic services rather than preventative or screening services.

One might think because the diagnostic mammography codes are being deleted from the Major Category IV list, hospitals will now be permitted to bill Medicare directly for diagnostic mammography services furnished to SNF residents. However, that does not appear to be the case. Rather, because these codes represent diagnostic services that fall within the scope of services covered under the SNF Prospective Payment System, it appears hospitals will need to continue to bill diagnostic mammography services furnished to SNF Part A residents to the SNF rather than to Medicare directly.

As usual, hospitals should confirm the implications of this change with their local FI (or MAC).

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