CMS Pub. 100-04, ch. 6, § 20.3

The following services may be billed separately under Part B by the rendering provider,

supplier, or practitioner (other than the SNF that receives the Part A PPS payment) and

paid to the entity that furnished the service. These services may be provided by any

Medicare provider licensed to provide them, other than the SNF that receives the Part A

PPS payment, and are excluded from Part A PPS payment and the requirement for

consolidated billing, and are referred to as “Major Category III” for consolidated billing

edits applied to claims submitted to A/B MACs (A).

• A medically necessary ambulance trip (other than a transfer to another

SNF) that transports a beneficiary to the SNF for the initial admission or

from the SNF following a final discharge, or that occurs pursuant to the

offsite provision of Part B dialysis services (see section 20.3.1 for

additional situations involving ambulance transportation);

• Certain chemotherapy (that is, anti-cancer) drugs. The chemotherapy

exclusion applies solely to the particular chemotherapy codes designated

under Major Category III.A of the SNF website’s A/B MAC (A) Annual

Update. These same codes also appear on the list of exclusions in File 1

of the SNF website’s A/B MAC (B) Annual Update (though not displayed

as a separate subcategory). The excluded chemotherapy codes serve to

identify those high-intensity chemotherapy drugs that are not typically

administered in a SNF, are exceptionally expensive, or require special

staff expertise to administer. By contrast, chemotherapy drugs that are

relatively inexpensive and are administered routinely in SNFs do not

qualify for this exclusion and, thus, remain subject to SNF CB. Further,

this exclusion would not encompass any related items that, while

commonly furnished in conjunction with chemotherapy, are not

themselves inherently chemotherapeutic in nature (that is, they specifically

address the side effects of the chemotherapy rather than actively fighting

the cancer itself). Examples of such chemotherapy-related drugs would

include anti-emetics (anti-nausea drugs), as well as drugs that function as

an adjunct to an anti-emetic, such as an anti-anxiety drug that helps to

relieve anticipatory nausea. Even when furnished in conjunction with a

chemotherapy drug that is itself excluded (and, thus, separately payable

under Part B), these related drugs would remain subject to SNF CB.

Similarly, if a drug designated by one of the excluded chemotherapy codes

is prescribed for a use that is not actually associated with fighting cancer,

it would no longer be considered an excluded “chemotherapy” drug in

such an instance, because it is not being used for a chemotherapeutic

purpose within the meaning of this exclusion.

• Certain chemotherapy administration services. The chemotherapy

administration codes are included in SNF PPS payment for beneficiaries in

a Part A stay when performed alone or with other surgery, but are

excluded if they occur with the same line item date of service as an

excluded chemotherapy agent. A chemotherapy agent must also be billed

when billing these services, and physician orders must exist to support the

provision of chemotherapy;

• Certain radioisotope services;

• Certain customized prosthetic devices (see §10);

• Effective for items and services furnished on or after October 1, 2021,

certain blood clotting factors indicated for the treatment of hemophilia and

other bleeding disorders;

• The transportation costs of electrocardiogram equipment (HCPCS code

R0076), but only with respect to those for electrocardiogram test services

furnished during 1998; and

• All services provided to risk-based MCO beneficiaries. These

beneficiaries may be identified with a label attached to their Medicare card

and/or a separate health insurance card from an MCO indicating all

services must be obtained or arranged through the MCO (as noted

previously in §10, consolidated billing applies only to Medicare fee-for-service beneficiaries).

The HCPCS code ranges for chemotherapy, chemotherapy administration, radioisotopes,

customized prosthetic devices, and blood clotting factors are set in statute. The statute

also gives the Secretary authority to make modifications in the particular codes that are

designated for exclusion within each of these service categories. See §10.1 above for the

link to where transmittals providing current lists of HCPCS codes used for Major

Category III SNF consolidated billing editing for A/B MACs (A) can be found.