Neurology & Pain Management Coding Alert

You must report the technical component of diagnostic tests to SNFs

When skilled nursing facility (SNF) patients present to your neurology practice for diagnostic testing, you're going to have to alter your reporting practices to receive the payment you deserve.
 
The Balanced Budget Act of 1997 requires SNFs to consolidate their billing for Medicare Part A (and some Part B residents). If your practice reports every single service for SNF patients directly to Medicare, now's the time to involve the nursing facility in your coding process -- or be ready to lose deserved reimbursement.

1. Collect Technical Components From SNF

Suppose a SNF patient presents to your practice for electromyography (EMG) of four extremities (95864, Needle electromyography; four extremities with or without related paraspinal areas). The neurologist performs the service and submits the claim directly to the patient's Medicare carrier. Under the new rules, however, Medicare will deny the claim, leaving the neurologist short the approximately $200 that he normally collects for four-extremity EMG services.

"Medicare carriers will no longer make payment to physicians and suppliers for technical components of physician services furnished to beneficiaries in the course of a Medicare Part A covered stay," according to CMS Program Memorandum B-00-67. In other words, a physician providing services to an SNF patient cannot expect payment for the technical component of any services directly from Medicare.

Solution: You can still collect your EMG reimbursement, but prepare for extra work. Report your professional component directly to the Medicare carrier (95864-26, Professional component), which allows you to collect the approximately $115 (according to 2004 Physician Fee Schedule database figures) allotted for the professional portion.

And you don't have to write off the $80 that Medicare allots for the technical portion of the claim. Instead, you should collect it directly from the SNF, says Deb Hudson, CCS-P, coder at the Mason City Clinic, a 35-physician multispecialty practice in Iowa. Medicare will pay the SNF for the technical portion, and you should therefore develop a relationship with the SNFs in your area and remind them that you will bill them directly for such services.

Most of the time, this will mean that you report the claim to the SNF exactly as you would bill it to Medicare. In the above example, you would report 95864-TC (Technical component) to the SNF, along with the appropriate ICD-9 code.

But don't wait until after you see the patient to coordinate your efforts with the SNF, Hudson says. When the SNF calls your practice to set the appointment, your receptionist should put a note on the patient's fee ticket indicating that she resides in an SNF.

"When the fee ticket gets to the coder, he or she should create another, separate fee ticket," Hudson says. "The fee ticket for professional services will go to the patient's Medicare carrier, and the other fee ticket, for technical services, will go to the SNF with modifier -TC."
 
2. Hold SNFs Responsible for Global Therapy Fees

If your practice provides physical, occupational and speech therapy services -- as well as some muscle and range-of-motion tests -- to SNF Part B residents, you should report the entire service directly to the SNF for payment. This is because even though most consolidated billing rules apply only to residents of Part A stays, therapy services for Part B residents are also subject to the guidelines.

Note: For a list of neurology-specific codes subject to consolidated reporting requirements, see "Want to Know Which Codes to Report Directly to SNFs? Here They Are".

Real-World Example #1: The neurologist provides range-of-motion testing of the upper limbs for an SNF Part B resident who has recently fallen. Although you should code this service as normal using 95851 (Range-of- motion measurements and report [separate procedure]; each extremity [excluding hand] or each trunk section [spine]) x 2 (one for each limb), you should report the procedure codes to the SNF. If you bill Medicare directly for this service, you will receive zero reimbursement.

3. Report E/M Services as Usual

Your neurologist's E/M services do not fall under consolidated billing rules, says Paula Roland, office manager for Michael Pushkarewicz, MD, in West Grove, Pa. The standard E/M rules still apply, however. For example, if the neurologist performs an E/M service with another procedure, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to your E/M code (for example, 99201-99215 for outpatient services).

Real-World Example #2: A SNF resident whom your neurologist has seen before presents to your practice complaining of arm and wrist pain. Your neurologist performs a level-three office visit and a motor nerve conduction study. You should submit the following codes to the patient's Medicare carrier: