Wiki Reimbursement for codes exempt from SNF consolidated billing rules

[mlovorn1]

We are having issues with claim payments being recouped by UHC Medicare Advantage/Dual Complete citing consolidated billing since the patient is inpatient SNF. However, everything I have read on consolidated billing states there are exemptions for procedures that are out of the scope of the SNF and performed outside of their facility. I even located a spreadsheet on the CMS website that lists the codes that are considered exempt and filed appeals citing all of the rules, but the denials are being upheld. Any suggestions or insight?

 

[Papitha]

I thought that the below tree would be useful to determine appropriate decision.



Reference link:

https://society.asco.org/sites/new-www.asco.org/files/content-files/practice-patients/documents/SNF-Consolidated-Billing.pdf

Hope this helps!