CMS Pub. 100-04, ch. 6, § 110.2.5

Per the Balanced Budget Act, services provided by CSWs to beneficiaries in a Part A

SNF stay may not be billed separately to the A/B MAC (B). Payment for these services

is included in the prospective payment rate paid to the SNF by the A/B MAC (A).

Though the policy was in effect since April 1, 2001, there were no corresponding edits.

With the April 2003 release, CWF implemented a new SNF consolidated billing edit to

prevent payment to CSWs for services rendered to beneficiaries in a Part A SNF stay.

Effective April 1, 2003, CWF established the new edit 7269 for services rendered to these

beneficiaries with dates of service on or after April 1, 2001, for claims received on or

after April 1, 2003. Once CWF determines that a beneficiary is in a Part A stay, prior to

applying the edits that review procedure codes to determine if payment should be

allowed, CWF will review the performing provider type of the submitting entity. If the

performing provider type is 80, CWF will reject the claim to the A/B MAC (B) or return

an unsolicited response with new error code 7269. The A/B MAC (B) will then take the

same adjustment and recovery action as for other rejects and unsolicited responses.

When A/B MACs (B) receive the new reject code, they must deny the claim and use the

following RA and MSN messages.

The contractor shall use the following remittance advice messages and associated codes

when rejecting/denying claims under this policy. This CARC/RARC combination is

compliant with CAQH CORE Business Scenario Three.

Group Code: CO

CARC: 96

RARC: N121

MSN: 13.10

Effective for claims with dates of service on or after April 1, 2001, CWF implemented

revisions on January 2, 2008 to bypass edit 7269 when a claim with a date of service on

or after April 1, 2001 is submitted and the date of service is within the From/Thru dates

with an occurrence Span code date of 74, 76, 77, 79, or M1 reported on a SNF inpatient

claim 21x in history or the date of service is greater than the occurrence date on a SNF

inpatient claim 21x in history with an occurrence code date of A3, B3, or C3. This will

allow for services to be separately payable outside of SNF consolidated billing during

non-covered periods in the SNF.