The Centers for Medicare & Medicaid Services (CMS) has made changes to the relative value files affecting 2017 Medicare Part B fee schedules. This will affect skilled nursing facility (SNF) providers that bill for Part B therapy services, the newly established physical and occupational therapy evaluation codes—97161, 97162, 97163, 97165, 97166 and 97167—and the occupational therapy re-evaluation code, 97168.
CMS has instructed Medicare Administrative Contractors (MAC) to update their systems for this change effective April 3, 2017; however, the rates are retroactive to January 1, 2017, service dates. MACs won’t be making mass adjustments for these changes; however, SNFs can choose to manually adjust claims containing these procedure codes to receive the updated payment amounts. For claims billed after April 3, 2017, the updated payment amounts should be correctly paid by MACs. For more information on this change, view the MLN Matters® article MM9977.
We recommend updating the fee schedule amounts in your billing software for the affected procedure codes effective with the date you’ll be billing for updated payment amounts. View updated Part B fee schedules here.
In addition, SNF providers with Wisconsin Physician Service Insurance Corporation (WPS) as a MAC should be aware WPS issued a notice of new system edits for prepayment review. The new edit will identify SNF Part A claims containing rehab ultra-high (RU) resource utilization groups (RUG) with a reason code of 51SNF. Although the medical review department of WPS confirmed reviews are random, providers with high RU code usage may see an increase in review.
Billing staff should always be alert for prepayment review, as claims will reflect a suspense status of SB600X. Providers should have a designated team member responsible for ensuring that information is compiled and submitted on time. Providers have 45 days to respond to prepayment review, or denial is issued. Payments cannot be issued for claims in review, so untimely responses can have a negative effect on cash flow.
Contact your BKD advisor with questions or for more information.