CMS Pub. 100-04, ch. 6, § 20.1.1

From Part A PPS Payment and the Consolidated Billing Requirement

(Rev. 12283, Issued:10-05-23, Effective:01-08-24, Implementation:01-08-24)

Except for the therapy services (see §20.5), physician’s professional services and

services of certain nonphysician providers listed below are excluded from Part A PPS

payment and the requirement for consolidated billing, and must be billed separately by

the practitioner to the A/B MAC (B). See below for Rural Health Clinic

(RHC)/Federally Qualified Health Center (FQHC) instructions.

For this purpose “physician service” means the professional services of the physician as

defined under the Medicare physician Fee Schedule. For services that contain both a

technical component and a professional component, the technical component, if any,

must be billed by the SNF for its Part A inpatients. The A/B MAC (B) will pay only the

professional component to the physician. For example, the technical component of a

diagnostic radiology test (representing the performance of the procedure itself) is subject

to SNF CB, whereas the professional component (representing the physician’s

interpretation of the test results) is excluded and, thus, remains separately billable under

Part B.

• Physician’s services other than physical, occupational, and speech

language pathology services furnished to SNF residents;

• Physician assistants, working under a physician’s supervision;

• Nurse practitioners and clinical nurse specialists working in collaboration

with a physician;

• Certified nurse-midwives;

• Qualified psychologists;

• Marriage and family therapists;

• Mental health counselors; and

• Certified registered nurse anesthetists.

SNF CB excludes the categories of practitioner services described above, and this

exclusion applies specifically to those professional services that ordinarily require

performance by the practitioner personally (see the regulations at 42 CFR 411.15(p)(2)(i)

and 415.102(a)(3)). This means, for example, that an otherwise bundled task (such as a

routine blood draw) cannot be converted into an excluded physician service merely by

having a physician perform it personally, as such a task does not ordinarily require

performance by the physician. This exclusion also does not encompass services that are

performed by someone else as an incident to the practitioner’s professional service. Such

“incident to” services remain subject to SNF CB and, accordingly, must be billed to

Medicare by the SNF itself (see §10.3).

Providers with the following specialty codes assigned by CMS upon enrollment with

Medicare are considered physicians for this purpose. Some limitations are imposed by

§§1861(q) and (r) of the Act. These providers may bill their A/B MAC (B) directly.

Physician Specialty Codes

01 General Practice 02 General Surgery

03 Allergy/Immunology 04 Otolaryngology

05 Anesthesiology 06 Cardiology

07 Dermatology 08 Family Practice

10 Gastroenterology 11 Internal Medicine

Physician Specialty Codes

12 Osteopathic Manipulative Therapy 13 Neurology

14 Neurosurgery 16 Obstetrics Gynecology

18 Ophthalmology 19 Oral Surgery (Dentists only)

20 Orthopedic Surgery 22 Pathology

24 Plastic and Reconstructive Surgery 25 Physical Medicine and Rehabilitation

26 Psychiatry 28 Colorectal Surgery (formerly Proctology)

29 Pulmonary Disease 30 Diagnostic Radiology

33 Thoracic Surgery 34 Urology

35 Chiropractic 36 Nuclear Medicine

37 Pediatric Medicine 38 Geriatric Medicine

39 Nephrology 40 Hand Surgery

41 Optometry 44 Infectious Disease

46 Endocrinology 48 Podiatry

66 Rheumatology 69 Independent Labs

70 Multi specialty Clinic or Group Practice 76 Peripheral Vascular Disease

77 Vascular Surgery 78 Cardiac Surgery

79 Addiction Medicine 81 Critical Care (Intensivists)

82 Hematology 83 Hematology/Oncology

84 Preventive Medicine 85 Maxillofacial Surgery

86 Neuropsychiatry 90 Medical Oncology

91 Surgical Oncology 92 Radiation Oncology

93 Emergency Medicine 94 Interventional Radiology

98 Gynecological/Oncology

Nonphysician Provider Specialty Codes

99 Unknown Physician Specialty

42 Certified Nurse Midwife 43 Certified Registered Nurse Anesthetist,

Anesthesia Assistants (effective 1/1/89)

50 Nurse Practitioner 62 Clinical Psychologist (billing

independently)

68 Clinical Psychologist 89 Certified Clinical Nurse Specialist

97 Physician Assistant

NOTE: Some HCPCS codes are defined as all professional components in the fee

schedule. Fee schedule definitions apply for this purpose.

Effective July 1, 2001, the Benefits Improvement and Protection Act (BIPA) established

payment method II, in which CAHs can bill and be paid for physician services billed to

their A/B MAC (A). CAHs must bill the professional fees using revenue codes 96x, 97x,

or 98x on an 85x type of bill (TOB). Like professional services billed to the A/B MAC

(B), the specific line items containing these revenue codes for professional services are

excluded from the requirement for consolidated billing.

RHC/FQHC Instructions:

Effective January 1, 2005, section 410 of the Medicare Prescription Drug, Improvement,

and Modernization Act of 2003 (MMA) amended the SNF consolidated billing law to

specify that when a SNF’s Part A resident receives the services of a physician (or another

type of practitioner that the law identifies as being excluded from SNF consolidated

billing) from a RHC or a FQHC, those services are not subject to CB merely by virtue of

being furnished under the auspices of the RHC or FQHC. Accordingly, under section

410 of the MMA, services otherwise included within the scope of RHC and FQHC

services that are also described in clause (ii) of section 1888(e)(2)(A) are excluded from

consolidated billing, effective with services furnished on or after January 1, 2005. Only

this subset of RHC/FQHC services may be covered and paid separately when furnished

to SNF residents during a covered Part A stay (see the regulations at 42 CFR

411.15(p)(2)(xvii) and 405.2411(b)(2)). Use TOBs 71x and 73x, respectively, to bill for

these RHC/FQHC services. See Pub. 100-02, Medicare Benefit Policy Manual, chapter

13 for additional information on Part B coverage of RHC/FQHC services.