CMS Pub. 100-04, ch. 6, § 20.5

Therapy services are edited as inclusions, rather than exclusions, to consolidated billing.

Physical therapy, speech-language pathology services, and occupational therapy are

bundled into the SNF’s global per diem payment for a resident’s covered Part A stay.

They are also subject to the SNF “Part B” consolidated billing requirement (for services

furnished to SNF residents during noncovered stays) and must be billed by the SNF

alone for its Part B residents on a 22x type of bill.

As noted in section 10.3 of this chapter, therapy services furnished to SNF residents

remain subject to consolidated billing even when performed by a type of practitioner,

such as a physician, whose services would otherwise be excluded (see section

1888(e)(2)(A)(ii) of the Social Security Act and the regulations at 42 CFR

411.15(p)(1)(i)). Further, while most services either clearly fall within the category of

therapy or clearly fall outside of it, there are a few services (such as certain debridement

codes) which, based on the specific type of practitioner involved, are sometimes

considered “therapy” services and other times not. However, because the consolidated

billing provision focuses on the nature of the therapy service itself (rather than the type of

practitioner who happens to be performing it), these “sometimes therapy” codes are

always considered therapy services in the specific context of SNF consolidated

billing. This means that a practitioner who furnishes such a service to an SNF resident

must always look to the SNF itself (rather than to Part B) for payment.

SNF residents that fall below a Medicare skilled level of care may be moved out of the

SNF or certified distinct part unit (DPU) to the Medicare non-certified area of the facility.

In doing so, the beneficiary is no longer subject to the SNF consolidated billing rule and

therapy services may be billed directly to Medicare by the provider rendering the service

or if billed by the SNF should be submitted on a 23x type of bill. If the entire facility

qualifies as a Medicare-certified SNF, all Part B therapies must continue to be billed by

the SNF on a 22x type of bill. The CWF SNF CB therapy edit will be bypassed for 22x

bill types that contain therapy services when those line item dates of service fall within a

non-covered period reported on an inpatient 21x bill type. For additional instructions, see

Chapter 7, SNF Part B Billing, section 10.1. In transmittals for A/B MAC (A) billing

providing the annual update list of HCPCS codes affected by SNF consolidated billing,

such services are referred to as “Major Category V” of SNF consolidated billing. See

section 10.1 above for the link to where transmittals providing current lists of HCPCS

codes used for Major Category V can be found.