CMS Manual System
CMS Manual System
Department of Health &
Human Services (DHHS)
Pub. 100-04 Medicare Claims Processing Centers for Medicare &
Medicaid Services (CMS)
Transmittal 185
Date: MAY 28, 2004
CHANGE REQUEST 3212
I. SUMMARY OF CHANGES: This transmittal notifies the carriers of additional
HCPCS codes for drugs and CPT codes for electrocardiogram testing to be added to
Common Working File Skilled Nursing Facility Consolidated Billing bypass for Part B
ambulance service claims billed to the carrier. The transmittal also provides instructions
for processing claims for these services when billed separately to the carrier.
NEW/REVISED MATERIAL - EFFECTIVE DATE: October 1, 2004
*IMPLEMENTATION DATE: October 4, 2004
Disclaimer for manual changes only: The revision date and transmittal number apply
to the red italicized material only. Any other material was previously published and
remains unchanged. However, if this revision contains a table of contents, you will
receive the new/revised information only, and not the entire table of contents.
II. CHANGES IN MANUAL INSTRUCTIONS: N/A
(R = REVISED, N = NEW, D = DELETED) – (Only One Per Row.)
R/N/D CHAPTER/SECTION/SUBSECTION/TITLE
R
15/30.2.3/SNF Billing
*III. FUNDING:
These instructions shall be implemented within your current operating budget.
IV. ATTACHMENTS:
X Business
Requirements
X Manual
Instruction
Confidential
Requirements
One-Time
Notification
Recurring Update Notification
*Medicare contractors only
Attachment - Business Requirements
Pub. 100-04
Transmittal: 185 Date: May 28, 2004
Change Request 3212
SUBJECT: Change to the Common Working File (CWF) Skilled Nursing Facility (SNF)
Consolidated Billing (CB) Edits for Drugs and Electrocardiogram (EKG) Testing
Provided During an Ambulance Transport
I. GENERAL
INFORMATION
A. Background:
Effective April 1, 2002, CWF edits were implemented to identify HCPCS codes for ambulance
services that are either subject to or excluded from Skilled Nursing Facility (SNF) consolidated
billing (CB). This coding change added SNF CB edits to CWF to deny payment of some
separately billed ambulance services for beneficiaries in a SNF Part A covered stay. Effective
July 1, 2003, CWF added an edit to allow claims submitted with specialty type “59” and
HCPCS codes J7030 or J7050 (Saline Solution Injection) to process and pay correctly for
modifiers other than “NN” when a beneficiary is in a Part A stay, and for claims submitted
with an “NN” modifier when the beneficiary is not in a Part A stay. Since the implementation
of this update, CMS has identified additional HCPCS codes for drugs and CPT codes for
electrocardiogram (EKG) testing that may be separately payable when provided during a SNF
ambulance transport that is not subject to SNF CB. HCPCS J-codes (J0000-J9999) not
included in previous updates, Q-codes for anti-emetic drugs (Q0163 through Q0181), and CPT
codes for EKG testing (93005 and 93041) will be added to the CWF SNF CB bypass for
ambulance specialty type “59” carrier claims during the October 2004 SNF CB quarterly
update.
B. Policy:
When not subject to SNF CB, claims for drugs and EKG testing provided during an ambulance
transport to or from a SNF are separately payable through the end of the Ambulance Fee
Schedule (AFS) transition period in those carrier jurisdictions that allowed separate billing for
these services prior to the implementation of the AFS. (These services are separately payable
only for Method 3 and 4 ambulance suppliers.) In those jurisdictions that allow separate
payment for drugs and/or EKG testing, carriers apply the appropriate reasonable charge
percentage for the AFS transition year (40% in 2004) to the reasonable charge amount for these
codes. (Because separately billable items are not recognized under the fee schedule, there is no
fee schedule portion for these codes.) In jurisdictions where separate payment for drugs and/or
EKG testing was not permitted prior to April 1, 2002, carriers must continue to deny supplier
claims for these services when billed separately. See Section 30.2.3 of the Medicare Claims
Processing Manual, Chapter 15, “Ambulance” for the complete set of the SNF CB rules
applicable to ambulance transports.
C. Provider
Education: None.
II. BUSINESS
REQUIREMENTS
“Shall" denotes a mandatory requirement
"Should" denotes an optional requirement
Requirement # Requirements
Responsibility
3212.1
Carriers that allowed, prior to April 1, 2002,
Local Part B Carriers
separate payment for drugs and/or EKG testing
when provided during a covered SNF
ambulance transport not subject to SNF CB
shall continue to pay claims for the separately
billable HCPCS J-codes (J0000-J9999), Q-
codes (Q0163 through Q0181), and EKG
testing CPT codes (93005 and 93041) through
the end of the AFS transition period, December
31, 2005. Carriers eligible to pay for these
services shall apply the appropriate reasonable
charge percentage for the AFS transition year to
the reasonable charge amount for the allowable
codes.
3212.2
Carriers that did not allow, prior to April 1,
Local Part B Carriers
2002, separate payment for drugs and/or EKG
testing provided during a covered SNF
ambulance transport not subject to SNF CB
shall continue to deny claims for separately
billed HCPCS J-codes (J0000-J9999), Q-codes
(Q0163 through Q0181), and EKG testing CPT
codes (93005 and 93041).
III. SUPPORTING INFORMATION AND POSSIBLE DESIGN CONSIDERATIONS
A.
Other Instructions: N/A
X-Ref Requirement # Instructions
B.
Design Considerations: N/A
X-Ref Requirement #
Recommendation for Medicare System Requirements
C. Interfaces:
N/A
D. Contractor
Financial
Reporting /Workload Impact: N/A
E. Dependencies: N/A
F. Testing
Considerations: N/A
IV. SCHEDULE, CONTACTS, AND FUNDING
Effective Date: October 1, 2004
These instructions shall be
implemented within your current
Implementation Date: October 4, 2004
operating budget.
Pre-Implementation Contact(s): Susan Webster
(410) 786-3384
Post-Implementation Contact(s): Susan Webster
(410) 786-3384
30.2.3 - SNF Billing
(Rev. 185, 05-28-04)
SNF-516.2, SNF QA Day4
The following ambulance transportation and related ambulance services for residents in a
Part A stay are not included in the PPS rate. They may be billed as Part B services by the
supplier in only the following situations.
• The ambulance trip is to the SNF for admission (the second character
(destination) of any ambulance HCPCS code modifier is N (SNF) other than
modifier QN, and the date of service is the same as the SNF 21X admission date.)
• The ambulance trip is from the SNF to home (the first character (origin) of any
HCPCS code ambulance modifier is N (SNF)), and date of ambulance service is
the same date as the SNF through date, and the SNF patient status (FL 22) is other
than 30.)
• The ambulance trip is to a hospital based or nonhospital based ESRD facility
(either one of any HCPCS code ambulance modifier codes is G (Hospital based
dialysis facility) or J (Nonhospital based dialysis facility).
• The ambulance trip is from the SNF to another SNF (the first and second
character (origin and destination) of any ambulance HCPCS code modifier is
“N” (SNF)) and the beneficiary not in a Part A stay.
Ambulance associated with the following outpatient hospital service exclusions payment
is under the ambulance fee schedule:
• Cardiac catheterization;
• Computerized axial tomography (CT) scans;
• Magnetic resonance imaging (MRIs);
• Ambulatory surgery involving the use of an operating room;
• Emergency services;
• Angiography;
• Lymphatic and Venous Procedures; and
• Radiology therapy.
Finally, ambulance transportation for removal, replacement, and insertion of PEG tubes is
an excluded service under consolidated billing for Part A and is not considered an SNF
service. Therefore, that ambulance is also excluded from SNF consolidated billing (CB),
and the service would be billed to the carrier under Part B.
When not subject to SNF CB, claims for drugs and EKG testing administered during a
transport to or from a SNF are separately payable during the AFS transition period only
in those carrier jurisdictions that allowed separate payment for J-codes and EKG testing
prior to the implementation of the AFS. (Only Method 3 and Method 4 suppliers in
carrier jurisdictions that allowed separate payment for these services prior to April 1,
2002 may bill separately for J-codes and EKG testing during the transition period.)
Carriers in those jurisdictions that allow separate billing for J-codes and EKG testing
apply the appropriate reasonable charge percentage for the AFS transition year (40% in
2004) to the reasonable charge amount for these codes. (Because separately billable
items are not recognized under the fee schedule, there is no FS portion for these codes.)
In jurisdictions where separate payment for J-codes and EKG testing was not permitted
prior to April 1, 2002, carriers shall deny supplier claims for such services.
The following ambulance transportation and related ambulance services for residents in
a Part A stay are included in the SNF PPS rate and may not be billed as Part B services
by the supplier. In these scenarios, the services provided are subject to SNF CB and the
first SNF is responsible for billing the services to the intermediary:
• A beneficiary’s transfer from one SNF to another before midnight of the same
day. The first and second characters (origin and destination) of any HCPCS code
ambulance modifier are “N” (SNF).
• A transport between two SNFs is not separately payable when a beneficiary is in
a Part A covered SNF stay, and will result in a denial of a claim for such a
transport. When billing for ambulance transports, suppliers should indicate
whether the transport was part of a SNF Part A covered stay, using the
appropriate origin/destination modifier (e.g., “NH” for a transport from a SNF to
a hospital).
• 
