How No Pay Bills Will Affect Part B Therapy Claims
Providers continue to have questions regarding
regulations of the Consolidated Billing (CB) requirement, established
initially as specified in the Balanced Budget Act of 1997. Each
year, the Centers for Medicare and Medicaid (CMS) issue updates to CB
to further clarify the regulations or to revise the services that are
considered excluded (or included) in the rules.
Change Request (CR) 5757 dated 11/2/07 further clarifies additional
Common Working File (CWF) editing for SNF Consolidated Billing to
ensure that all therapy services are subjected to SNF CB edits when
provided in a covered or non-covered SNF stay. The effective date of
these edits was April 7, 2008.
According to MLN Matters # MM5757, “Since therapy services
provided in a SNF must be consolidated when a beneficiary is in a SNF
stay , whether covered or non-covered by Medicare, Medicare systems
will reject claims within dates of service falling within a SNF stay.
As a result of this specific change, Medicare’s CWF system will
reject claims with dates of service after the posted SNF claim until a
discharge claim is processed. The entity furnishing the therapy
services must look to the SNF for payment, rather than billing
Medicare.”
With the issuance of CR 5757, nursing facilities must file the no-pay
claim monthly for residents who are receiving Part B therapy services
in the nursing facility. For example; resident Jane Doe utilizes 60
Medicare Part A benefit days at which time she is cut from a skilled
level of care. The facility must “end” the benefit period
for Jane Doe with a 213 bill type, a 30 status code (still a resident)
and an occurrence code 22, indicating the last covered day of skilled
care. At this time, the facility had the option of filing no-pay claims
each month OR filing a final no-pay claim upon the resident’s
permanent discharge from the facility. If the no-pay claim is not
filed, the Medicare system will reflect that the resident remains in a
skilled stay and the Part B therapy claims will be rejected.
Official instruction (CR5757) can be found at:
http://www.cms.hhs.gov/transmittals/downloads/R1365CP.pdf
Further information on Consolidated Billing can be found at:
http://www.cms.hhs.gov/SNFConsolidatedBilling/.
