Gastroenterology Coding Alert

Question: We saw a patient last month to treat her for colitis and we didn’t realize she was from a skilled nursing facility (SNF). This has caused massive billing issues up the chain and we’re now having to go after the SNF for the money (which is where Medicare sent the payments). What can we do to prevent this in the future? It has taken up a lot of time for our practice to fix.

Iowa Subscriber

Answer: Unfortunately, this situation is common, but it can be remedied by taking some preventive measures. Medicare 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).

The first step in consolidated billing is to develop a system to identify Part A SNF-stay patients seen in the office. 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 with the Part A-stay patient instructing the physician’s office 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 office by SNF staff, or they could present with a family member. So, it’s up to your practice to get this information up front.

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. 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 office.

Develop a one-page contract for you to use with SNFs — this is helpful whether your physician is seeing a SNF patient in the office or if they are going to the SNF to treat patients there. 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.

Note: 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. Also note that many SNF residents are not receiving skilled nursing benefits but are longer-term residents of the facility, in which case the Part A consol­idated benefits are not applicable.