Skilled nursing facility consolidated billing enforcement: HCPCS code changes

Healthcare Common Procedure Coding System (HCPCS) codes play a critical role in the healthcare billing process. They ensure appropriate reimbursement for specific medical services provided to patients through Skilled Nursing Facility (SNF) Consolidated Billing (CB). The Centers for Medicare and Medicaid Services (CMS) oversees these codes and provides quarterly updates on changes. This article summarizes the HCPCS code changes mentioned in the July 2023 quarterly update relevant to Change Request 13192.

SNFs and other providers in the healthcare ecosystem should make sure that their billing staff are aware of these changes. Awareness of the HCPCS code changes is key to minimizing unexpected and unnecessary costs to patients or lost revenue.

The latest update brings several changes to the HCPCS codes used in consolidated billing at SNFs. It includes the addition and deletion of certain codes. The additions are mostly related to chemotherapy drugs, with specific new codes being introduced.

On the other hand, the deletions are mostly related to COVID-19 vaccines, vaccine administration, and monoclonal antibody treatment codes. These updates, while routine, have big effects on the payment process, impacting how providers bill for specific services.

Changes to approved services during Medicare Part A covered stays include chemotherapy injection additions, as well as additions and removals for vaccines.

HCPCS code changes to approved services during Medicare Part B uncovered stays include chemotherapy injection additions and removal of specific code ranges for vaccines. Removals are mostly related to COVID-19 vaccines, vaccine administration, monoclonal antibody treatment, and monoclonal antibody treatment administration.

These changes will impact services that are not part of the SNF Prospective Payment System (PPS) and CB. While Medicare covers some services provided by other healthcare entities, even during an SNF stay, it only covers services that are on the exclusion list.

Furthermore, the update introduces different rules for therapy and non-therapy services, adding complexity to the billing process. Providers need to understand these nuances to ensure accurate billing and proper reimbursement for provided services.

To ensure a smooth transition and adherence to the updated HCPCS codes, healthcare providers must take proactive steps. The first course of action is to ensure that their billing staff are up-to-date with the changes.

They need to understand the new codes, the services to which the codes apply, and how to use codes in billing processes. Failure to adhere to these changes could lead to incorrect billing and, subsequently, inaccurate reimbursements or even potential regulatory issues.

It’s vital that providers review their own claims and payments. CMS will not actively search for incorrectly paid claims based on the HCPCS code changes. This means that providers must be diligent in flagging any claims they believe might have been incorrectly paid. Medicare Administrative Contractors (MACs) will only reopen and reprocess claims that the providers bring to their attention.

Navigating the changes in the HCPCS codes requires a comprehensive understanding of the codes themselves and how they intersect with the delivery of healthcare services. It is crucial for providers to coordinate with their medical coders and billing team to align their billing processes with these changes. Providers should also consult with their billing software vendor or electronic data interchange (EDI) clearinghouse to make sure they are ready for the changes.

All providers should become familiar with the new codes so they know when and how to use them. Failure to implement strategies can result in claim denials and getting to the root of the issue is a cumbersome and labor-intensive process. Most denials are caused by incorrect coding. 

Remaining current with HCPCS code changes is vital for correct billing, proper payment, and compliance with CMS regulations. This ensures that healthcare providers can continue to focus on their primary task: providing quality care to their patients. More billing details are included in the updated consolidated billing lists.