Medicare Compliance & Reimbursement

Know the payment rules associated with SNF patients.

Occasionally, Medicare providers see skilled nursing facility (SNF) patients — 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.

That’s because 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: Before your practice can start billing for services you perform for nursing facility patients, you need to figure out what consolidated billing really is and why it matters to your billing process. “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,” Noridian continues. “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.”

Nuts and bolts: “Under consolidated billing, a SNF receives a basic per diem rate per level of care for each resident which covers all costs (routine, ancillary and capital) related to the services furnished to beneficiaries,” says Linda Smith, CPC, CMBS, owner of MedOffice Resources in Greene, New York. “The bundled services are billed by the SNF to a Part A MAC in a consolidated bill.”

Caveat: A SNF bills Medicare for services provided to resident patients. But Medicare excludes some categories of services from consolidated billing because they are costly or require specialization.

So in order for your practice to be reimbursed for any of the excluded services, you can contact Medicare Part B directly. However, for any services included in SNF consolidated billing, your practice has to work with the facility. 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 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.

Tip 2: Know What’s Included

Physicians’ 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 office.

Tip 3: Create A Contract

It can be helpful to develop a one-page contract for your practice to use with SNFs — whether your physician is seeing a SNF patient in the office or if he is 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 (see sample contract on p.52).

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.

Reference These 2 Scenarios for Billing Quandaries

Example 1: A 68-year-old Medicare beneficiary who has been followed by the pulmonologist for emphysema presents to the office for evaluation of increasing episodes of wheezing. The pulmonologist is aware that the patient is receiving a short course of inpatient Part A SNF care following a three-day hospitalization for uncontrolled diabetes mellitus and influenza with pneumonia.

The doctor orders a chest x-ray and pulse ox in the office. The chest x-ray is normal, and the pulse ox is 92 percent. He performs a focused exam, noting obvious wheezing upon chest auscultation. The pulmonologist asks the nurse to administer a nebulizer treatment for acute airway obstruction. The patient’s color improves following the treatment.

The pulmonologist calls the SNF geriatrician to provide an update on the patient’s worsening asthma and suggests nebulizer treatments be provided in the SNF for wheezing episodes. The pulmonary physician bills the SNF for the following services:

• The technical component of the x-ray if he or she owned the equipment
• The nebulizer treatment, which is considered respiratory therapy and covered by the SNF PPS.

For this claim, no modifier is needed.

The pulmonologist will receive reimbursement for the E/M service directly from the Part B MAC. “The pulse ox is typically bundled into payment for other services billed on the same day, so this should not be billed separately to either the SNF or Medicare Part B,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

Example 2: A 72-year-old Medicare beneficiary who has been treated by an ophthalmologist for retinopathy arrives from the SNF to your office. The ophthalmologist sees the patient and performs a level three office visit, as well as taking fundus photographs.

In this case, you’ll submit a claim to your Medicare Part B carrier for the E/M service and the professional component of the fundus photography, using CPT^® code 92250-26 (Fundus photography with interpretation and report; professional component). However, you’ll submit a claim to the SNF with 92250-TC (... technical component).

Resource: For a more in-depth overview of the various SNF billing issues, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/SNFSpellIllnesschrt.pdf.