Oncology & Hematology Coding Alert

When billing for skilled nursing facility (SNF) patients who present to your oncology practice for chemotherapy and associated services, you may be tempted to thank your lucky stars for the many oncology services that are excluded from consolidated billing but don't get smug yet. The Balanced Budget Act of 1997 requires SNFs to consolidate their billing for Medicare Part Aresidents, thus turning reimbursement into even more of a monster when it comes to nursing-home patients. If your oncologist is billing every single service for SNF patients directly to Medicare, don't expect more than consistent problems. Patients Suffer Most in the Long Run According to Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett, coordinating care for SNF patients not only creates a billing morass but also raises access-to-care issues. When patients are transferred from a hospital to an SNF, the SNF may be reluctant to accept those patients because the costly chemotherapy burden will fall on the nursing home's shoulders. While an SNF can't refuse a patient solely on account of cost, they have been known to use low staffing to justify turning patients away, says Rusti Bauman, RN, BSN, MS, a nurse consultant with FR&R Healthcare Consulting in Deerfield, Ill. Whether or not the SNF's tale of woe is true, all that oncology coders and billers can do is bite the bullet and "dive into that HCPCS code list and figure out on a case-by-case basis what you can bill," Bauman says. Chemo and J Codes Excepted From SNF Billing The list of codes that are excluded from consolidated-billing requirements includes the common chemotherapy administration codes (the 96400 series) and a fat selection of J codes. When you treat SNF patients, these procedures will get submitted to your Medicare carrier as normal, and you can expect your typical reimbursement, Towle says. Medicare will also pay for office visits when appropriate. Lab, Ancillary Services Are a Part of Consolidated Billing Unfortunately, the list of services that fall under consolidated-billing requirements and thus must be submitted directly to the nursing home is equally daunting.

Towle says that the list includes most laboratory services as well as any other ancillary services provided at the time of chemotherapy, the administration of antiemetics, growth factors and premedications such as hydration therapy, and non-chemotherapy infusions (90780-90781). None of these can be billed directly to Medicare; instead, they must be billed to the nursing home, which then reimburses the oncology practice. Clinical Example But don't think you can take refuge in easy generalizations, Bauman cautions. Even closely related codes can fall on different sides of the great consolidated-billing divide.

For example, suppose an SNF patient in a covered Part Awith a history [...]