Medicare Compliance & Reimbursement

If you write off X-ray fees for SNF patients, you could be forfeiting thousands by not following up on the X-ray fee's technical component.

The problem: Skilled nursing facilities (SNFs) must consolidate their billing for Medicare beneficiaries who are in a Part B non-covered SNF stay in which their Part A benefits are exhausted. When coding for these patients who present to private practices or clinics for X-rays, bill the physician's x-ray interpretation to Medicare with modifier 26 (Professional component) appended, but bill the technical component directly to the SNF.

Some practices find this procedure so frustrating that they write off the X-rays' technical portion, which can run anywhere from $17 for 73020-TC (One-view shoulder X-ray) to $52 for 72114-TC (Complete lumbosacral spine X-ray).

But if you see SNF patients frequently, these fees can add up, and writing them off is not a valid solution. These five steps can help you collect.

1. Determine the patient's SNF status: The ideal situation would be to determine the patient's SNF status when he calls to make the initial appointment. If the patient is in an SNF, the front office staff should get authorization to x-ray the patient and record the name of the SNF staffer who gave authorization.

But even if the receptionist tries to identify each SNF patient during the initial phone call, you may still miss some. In those cases, "You kind of need to be a detective," says Angie Good, CPC, of the Orthopaedic Institute of Ohio. "Observe who brought the patient in -- are they wearing a badge from a nursing home? Some patients come with a packet of papers from the nursing home that need to be filled out. Ask, ask, ask!"

Once you establish that the patient is in an SNF, you should flag his or her chart for future claims, says Jenny Harrison, of N'Orthopedics, PC, in Gaylord, MI.

2. Don't worry about lengthy SNF contracts. Although some orthopedic practices believe they have to write up complex contracts with the nursing home before they can capture payment for the x-rays' technical portions, this is not accurate. "A clarification from Medicare was issued in January 2005," Harrison says. "It states that an arrangement is validated not by written documentation, but rather compliance with requirements. We have three SNFs that we mainly deal with and have had no problems with them."

3. Don't waste time with big markups if you're dealing with multiple SNFs. Some orthopedic practices note that consolidated billing allows them to bill the SNF for a significantly higher amount than they would collect from Medicare. Their rationale is that because they are billing the SNF directly, they are no longer bound by Medicare's set fees.

In many cases, this is accurate. But some practices report that struggling to get additional dollars from the SNF over and above the fee schedule amount is not worth the time and effort.

"We probably could negotiate a higher fee, but we deal with over 60 skilled nursing facilities, and that would be quite the undertaking," Good says.

4. Don't let SNF ignorance stop your payments. In some cases, the SNF may not know why you're sending them a bill and consequently may deny payment. Take these experiences, and turn them into a chance to build a partnership with the SNF.

"I recently had this situation with a SNF that I had never dealt with before," Harrison says. "Fortunately, this was resolved with a phone call to the SNF administrator. I simply reminded them of the Medicare guidelines and requirements for this, and I received my payment within 10 days."

5. Don't write off the fees. "Every once in a while, we will get one that needs a little more effort with collecting than we would like, but we have never written one completely off," Good says. "They will pay."

And remember that SNF patients' X-ray fees add up. "Some of our SNF patients have multiple X-rays," Harrison says. "They may be small amounts, but they add up over a year. In this time of declining reimbursement, we need to collect every penny we are entitled to."