Gastroenterology Coding Alert

Do you know how to handle consolidated billing patient issues?

Whether you perform services in your office, the hospital, or even an ambulatory surgery center, it’s likely that you see skilled nursing facility (SNF) patients now and then – and although those visits are not usually all that different from standard patient encounters, they can be vastly different when it comes to the billing rules.

SNF patients are subject to consolidated billing regulations, and some auditors are taking notice of the fact that not every practice is heeding these rules. Part B RAC Cotiviti added an approved issue effective April 2, 2019 reminding practices that ASC services are included in the Consolidated Billing program.

In black and white: “Services provided by a freestanding non-hospital ASC (Ambulatory Surgery Center) are included under the SNF Consolidated Billing Provisions,” Cotiviti says. “Certain services are not payable because they are included in SNF Consolidated Billing. Codes found in the SNF Consolidated Billing – Part A MAC Updates for years: 2015, 2016, 2017 and 2018 are overpayments and will be recovered.”

Here’s why: The government requires SNFs to “consolidate” their billing for Medicare Part A-stay residents, and all but a few services are excluded from the prospective payment system (PPS). Physicians who bill Medicare for services that are part of the all-inclusive PPS rate could be setting themselves up for payment recoupments and potential fraud and abuse investigations.

In black and white: “For services and supplies furnished to a SNF resident covered under the Part A benefit, SNFs are not able to unbundle services to an outside provider of services or supplies that can then submit a separate bill directly to Medicare,” says Part B MAC Noridian Medicare on its website. “Instead, the SNF must furnish the services or supplies either directly or under an arrangement with an outside provider. The SNF, rather than the provider of the service or supplies, bills Medicare. Medicare does not pay amounts that are due to a provider of the services or supplies to any other entity under assignment, power of attorney, or any other direct payment arrangement. As a result, the outside supplier of the service or supplies must look to the SNF, rather than to the beneficiary or Medicare, for payment.”

To ensure that you’re reporting your services for SNF patients accurately, check out these three quick tips.

Tip 1: Identify These Patients

The first step in consolidated billing is to develop a system to identify Part A SNF-stay patients that your gastroenterologist sees. This may sound like a no-brainer, but much of the time it can be overlooked or missed.

Many SNFs send a form or notice to the physician’s office or the ASC with the Part A-stay patient instructing them to bill the SNF for services that are subject to consolidated billing. However, this step doesn’t always happen, and it’s up to you to find out when a patient is actually a SNF resident. They may be brought to your gastroenterologist by SNF staff, or they could present with a family member. So it’s up to your office to get this information up front.    

Tip 2: Know What’s Included

The gastroenterologist’s professional services are excluded from the Consol­idated Billing rule and are therefore separately payable, according to a CMS Fact Sheet on Consolidated Billing, which was last updated in June 2018. However, if the doctor performs a diagnostic test in addition to the visit, the technical portion of the diagnostic test does fall under the Part A consolidated billing rules. That’s when things get confusing, because payment for those line items will be sent to the SNF and not to your physician.

Tip 3: Create A Contract

Develop a one-page contract to use with SNFs – this is helpful whether your physician is going to the SNF to treat patients there or is seeing the patient outside of the SNF. The contract should list the physician’s billing information and include a disclaimer stating that you expect payment for services rendered regardless of the SNF’s reimbursement status with the Medicare carrier.

While a contract may not always eliminate problems, it gives you the legal boundaries to deal with payment issues.

Charge SNFs only for the reimbursement you could expect according to the Medicare fee schedule. You can’t tack on fees to account for driving time or gas costs related to SNF visits, even if you think you deserve pay for this.

Tip 4: Check This Example

A 68-year-old Medicare beneficiary who has been followed by the gastro­enterologist for Crohn’s disease presents to the office for evaluation of increasing episodes of rectal bleeding. The gastroenterologist is aware that the patient is receiving a short course of inpatient Part A skilled nursing facility care following a three-day hospitalization for uncontrolled diabetes mellitus and influenza.

The doctor orders a barium enema x-ray and performs a physical exam in the office. The x-ray is normal, and the exam reveals the presence of hemorrhoids. The gastroenterologist calls the SNF geriatrician to provide an update on the patient’s condition. The physician bills the SNF for the technical component of the x-ray if he or she owned the equipment

The gastroenterologist will receive reimbursement for the E/M service directly from the Part B MAC.