Neurology & Pain Management Coding Alert

Question: When our doctor orders a SNF (skilled nursing facility) patient to have diagnostic tests done at our office, they are denied by Medicare even though we use office as the place of service. Medicare still identifies the patient as being in a SNF. We are interested to know how the patient can have these tests performed. The EEG can be done in a hospital setting, but the EMG and NCS cannot only be in 'office' to get reimbursed.  So how does one get paid if patient needs to have this testing?

New York Subscriber

Answer: You can perform tests like EMG and NCS on a SNF patient in the office. However, you only bill Medicare Part B for the professional component of the diagnostic studies by appending the modifier 26 (Professional component) to the CPT® code.  Regardless of where the diagnostic study was performed, i.e. the physical location, Medicare includes the technical component of all diagnostic studies in the facility payment for Medicare Part A covered stays. As such, if your provider is performing / providing the technical component of the diagnostic study as well as the professional component, you would need to look to the SNF for coverage of the diagnostic study technical component.

Make sure you get an agreement set up with the SNF that they will pay for the TC modifier component of the charged CPT® codes.   In a very ideal situation where you know about this before the patient has the tests performed, you should get in touch with the SNF billing department get the agreement set. Also you should get to whom and where to mail the claim with the TC modifier.

Medicare may pay inadvertently for the technical component of the diagnostic study and later may realize that a SNF should be responsible. Medicare, in such a situation, may request a refunding.

You may actually refund and start over with splitting out the claim and contacting the SNF.  When you send the SNF claim, after Medicare pays and requests a refund, you may also send the Medicare remit that shows Medicare paid and then is requesting the refund and also state reasons for the same.