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Few drugs excluded from Part A Consolidated Billing

Some client communities have asked our pharmacy to look into whether some expensive medications might be candidates for exclusion from Medicare Part A Consolidated Billing and separately billable to Medicare Part B. In fact, very few drug preparations are excluded from the Consolidated Billing rules; they include certain medications related to the treatment of renal disease and some chemotherapy drugs. The Centers for Medicare and Medicaid (CMS) provides the following general guidance.

The consolidated billing requirement confers on the SNF the billing responsibility for the entire package of care that residents receive during a covered Part A SNF stay and physical, occupational, and speech therapy services received during a non-covered stay. Exception: There are a limited number of services specifically excluded from consolidated billing, and therefore, separately payable.

For Medicare beneficiaries in a covered Part A stay, these separately payable services include:

  • physician's professional services;
  • certain dialysis-related services, including covered ambulance transportation to obtain the dialysis services;
  • certain ambulance services, including ambulance services that transport the beneficiary to the SNF initially, ambulance services that transport the beneficiary from the SNF at the end of the stay (other than in situations involving transfer to another SNF), and roundtrip ambulance services furnished during the stay that transport the beneficiary offsite temporarily in order to receive dialysis, or to receive certain types of intensive or emergency outpatient hospital services;
  • erythropoietin for certain dialysis patients;
  • certain chemotherapy drugs;
  • certain chemotherapy administration services;
  • radioisotope services; and
  • customized prosthetic devices.

Institutional providers should contact their Part A Medicare Administrative Contractor (MAC) with questions about SNF consolidated billing. There is also additional information about SNF consolidated billing on the CMS Medicare Learning Network (MLN) website.

Additional information
If a skilled nursing community decides to provide a Part-A-excluded medication, the community must have a Medicare Part B provider number in order to receive Medicare Part B reimbursement. The patient must also be a Medicare Part B participant. In addition, the patient is responsible for any deductible or co-pay associated with his or her Medicare Part B coverage.

If your community is considering providing excluded medication, we strongly recommend that you contact your MAC to determine whether the drug in question is, in fact, on the excluded list – and to obtain guidance in providing the required billing documentation.

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