SNF’s Notice to a Hospital Treating a Beneficiary in a Medicare Part A Stay on an
(Sample Notification #6)
Reason for referral (e.g., emergency room, CT scan, outpatient surgery)
Mr./Ms. (patient’s name)
covered patient of (name of skilled nursing facility
is a Medicare Part A
and has been referred to your hospital
outpatient department for services that may be covered by the consolidated billing provisions of the Skilled Nursing Facility Prospective Payment System (PPS).
Under the consolidated billing provisions of the SNF PPS, the following services that may be required by the resident should be billed to Medicare as they are excluded from SNF PPS and must be billed separately by the rendering provider (hospital). Centers for Medicare & Medicaid Services (CMS) has identified these services by HCPCS code. Please refer to CMS annual and quarterly updates of HCPCS codes used for SNF consolidated billing for a complete list of separately billable services at www.cms.hhs.gov/providers/snfpps/snfpps_pubs.asp.
0 Emergency room procedures and supplies directly related and required to complete the procedure or treat the emergency condition.
0 Emergency room observation and any ancillary services provided if kept past midnight.
0 End stage renal disease services (free standing or hospital based).
0 Erythropoietin and Aranesp for ESRD patients on dialysis.
0 Physician visits - professional component including interpretation of tests.
0 Psychological services - psychologist or psychiatrist.
0 Chemotherapy provided for specific HCPCS codes.
0 Radioisotope services for specific HCPCS codes.
0 Customized prosthetics for specific HCPCS codes.
Note: The following services should also be billed by the hospital directly to Medicare.
0 Cardiac catheterization
0 PEG tube placement
0 Lymphatic procedures
0 CT scans
0 Radiation therapy
0 Ambulatory surgery (involving the use of an operating room
Note: Generally ambulatory surgery codes in the range from 10040 through 69979 are excluded and billed by the hospital. However, some minor surgical codes within that range are the responsibility of the SNF.
The Skilled Nursing Facility should be billed for the following services that may be required by the resident.
0 Administration of tests or services ordered by the physician - technical component and not listed in the above exclusions, e.g., x-ray, blood transfusion, lab work, modified barium swallow.
0 Durable medical equipment.
0 Non-emergency procedure not requiring the use of an operating room.
0 Services incident to physician services.
0 Chemotherapy and radioisotope services and prosthetic devices not excluded by
0 Other services unrelated to the visit.
Please contact (name)
if there are any questions.
at our SNF
Note: Please list the services provided and return this form to the SNF.