Major category V: Therapy services included in consolidated billing

May 02, 2019
The Bottom Line

Therapy services under major category V are included in the SNF daily rate and accounted for on the consolidated bill for beneficiaries who are in the midst of a Part A stay. However, once a beneficiary who also has a Part B plan exhausts his or her Part A benefits, the SNF must begin billing therapy services to Part B. Regardless of whether a SNF is submitting a claim for a beneficiary using Part A or Part B benefits, the provider should include the following revenue codes on the UB-04 to distinguish between the three therapy disciplines:

  • 42X (PT)
  • 43X (OT)
  • 44X (SLP)

Only the SNF may submit claims to Medicare for these three therapy disciplines, even if the service is provided by an outside therapy company. Those individuals who no longer qualify for Part A benefits and don’t have a Part B plan must either pay out of pocket or use an alternative insurance plan to cover these services. In such cases, the SNF would still be responsible for billing the appropriate entity (i.e., the beneficiary or the backup insurance plan).

Important Note: Although therapy services make up the only major CB category considered included, Medicare will only reimburse SNFs for them (and all other services, ancillary or otherwise) through the SNF daily rate when they are provided on covered days (i.e., those considered part of a Medicare Part A stay). For this reason, and many others, SNFs must always verify a beneficiary’s benefit status before ordering a service from an outside supplier, as facilities will still be held responsible for paying these providers regardless of whether a given service qualifies for Medicare reimbursement. For example, the day of discharge from the SNF is not a billable covered day, so Medicare will not pay for any therapy services delivered to the departing beneficiary on that day. However, the SNF is still responsible for paying any suppliers that render services to the individual on that day.

Tip: Some therapy services require special equipment and must be completed in a hospital setting. If the hospital is providing therapy services for a SNF resident (regardless of whether the beneficiary is in a Part A stay), the SNF must pay the hospital invoice for the services provided, but then the SNF can bill Medicare to be reimbursed for the services.

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