Medicare Compliance & Reimbursement
Let The Cat Out Of The Bag About CT Scans
Long-term care providers that do not communicate with clinicians about CT scans could get a big bill for a scan they shouldn't have to pay for.
In most cases, the Centers for Medicare and Medicaid Services excludes the cost of a resident's medically necessary CT scan from the per diem rate they pay nursing homes to care for Part-A stay residents, confirms Carol Maher, MDS coordinator for Manor Care in Citrus Heights, CA. But more than a few facilities take a wrong turn when sending patients for needed testing.
Potential problem: CT scans done at freestanding centers are not excluded from skilled nursing facility consolidated billing. If a resident receives a CT scan at a freestanding center, the provider can expect to receive - and pay - a hefty bill for the service.
Solution: Providers that steer clear of the freestanding center and send patients to a hospital or critical access hospital probably won't have to eat the cost. Instead, Med-icare Part B will cover a claim the hospital submits to its fiscal intermediary. That's because CT scans, in most cases, are what's known as a "Category 1 exclusion" from SNF consolidated billing.
What's fueling long-term care providers' confusion regarding consolidated billing restrictions on place of service for CT scans? In part, the increasing number of freestanding centers, cautions Ron Orth, director of clinical reimbursement for Extendicare Health Services, based in Milwaukee.
Translation: An unknowing clinician may find it convenient to send a resident to a nearby freestanding center, and it's up to managers to educate staff about the realities of consolidated billing.
Another potential problem: Not all CT-related HCPCS codes are listed as consolidated billing exclusions. Providers that fail to code properly could wind up with a bill even if the service is provided in a hospital or critical access hospital.
For example, a Part A stay resident comes to nursing home following hospitalization for a fall that resulted in a subdural hematoma. She requires a follow-up CT scan following admission to the facility.
To proceed, determine what HCPCS code will be used for the resident's CT scan - before the screening is done. If the code is listed under the exclusions on the consolidated billing transmittal, the facility shouldn't have to pay for the test.
Look out for ... : Providers should also be sure the billing office and other staff stay on top of CMS' annual and quarterly updates to HCPCS codes related to SNF consolidated billing.
Medicare Compliance & Reimbursement
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