Ophthalmology and Optometry Coding Alert

Determining whether a patient is in a Part A or Part B stay is your key to proper reimbursement.

When your ophthalmologist sees a nursing facility patient in your office, your challenge is collecting proper reimbursement for those services.

The problem: A patient's nursing facility NF status -- whether he is in a Part A-covered stay or a Part Bcovered stay -- determines how you should be billing for your ophthalmologist's services, and if you're not following consolidated billing rules you'll continue to sacrifice part of your fees.

Good news: If you follow three steps, you'll be well on your way toward proper billing and payment every time.

1. Understand Consolidated Billing and How It Affects

Your Practice Before you can start billing for services your ophthalmologist performs for nursing facility patients, you need to figure out what consolidated billing really is and why it matters to your billing process.

How it works: "Medicare's 'consolidated billing' is a payment methodology that reimburses nursing facilities in a lump sum payment for all facility services the patient may need during the course of a Part A nursing facility stay," explains Joan Gilhooly PCS, CPC, CHCC, a coding expert and president of Medical Business Resources in Lebanon, Ohio. "In addition to paying for the bed and nursing services the patient receives, the payment also covers other 'facility-type' services the patient may need to receive. The lump sum payment rate is the same whether the patient receives these additional services or not."

Here's why it matters: Because Medicare Part A typically covers nursing facility patients and consolidated billing rules apply, you can only report certain services to Medicare. When a patient  visits your office, if the patient is in a covered Part A stay, the facility is liable for the payment of any technical component services. These services include medications, lab work, x-rays (the technical portion, not the interpretation), the technical portion of EKGs, billable supplies, DME dispensed from office, etc.

"Obviously, Medicare doesn't want to pay for those services twice -- once to the nursing facility in that lump sum payment and second to the physician on an 'a la carte' basis," Gilhooly says. "As a result, if the patient is currently in the nursing facility covered under a Medicare Part A stay, the physician can only bill Medicare for his/her professional services. Any technical or 'facility' services that are needed to be performed during that office visit must be billed directly to the nursing facility. The physician should request reimbursement for billable supplies and/or technical component expenses your practice incurred during the encounter."

Note: To receive payment for the expenses you incurred for the technical aspects of services your physician performs, you may need to have an executed contract with the SNF. For a sample contract, see "Overcome Consolidated Billing Troubles With an SNF Contract."

2. Check the Patient's Status

To properly bill and collect for nursing facility patient services requires the practice to actually contact the facility to confirm whether the patient is in a Part A or Part B stay. If he is not covered by Part A, you may bill your Part B carrier for all the services you provide.

But if his nursing home stay is covered by Part A, you are about to enter the world of consolidated billing. "This really should start when the patient appointment is scheduled," Gilhooly says. Even If this has been established at the time the appointment is made she advises practices to contact the nursing facility on the day of the appointment to confirm whether the patient is in a Part A or Part B stay.

Warning: There is no way to guess if a patient is in a Part A or Part B stay, Gilhooly stresses. Even if a nursing facility has certain floors for "skilled nursing care," using that premise to assume the patient is a Part A admit is still a bad idea. "Check with the individual at the nursing home who maintains the SNF/NF's census," Gilhooly explains. "They will know, on a day-by-day basis, whether the patient is in a Part A stay versus a Part B stay (which can vary from one day to the next)."

3. Leave the Professional Portion to Medicare

For services with both a technical and a professional component that your physician performs for a nursing facility patient in your office, you should report only the professional component -- such as the written interpretation of an x-ray -- to your Medicare carrier/MAC.

And for many of the medications your physician might administer to a nursing home patient in a Part A stay, Medicare Part B will not reimburse you in the usual manner. Instead, you must submit a claim to, and seek payment from, the nursing facility itself for reimbursable expenses for medications, supplies, the technical components of diagnostic services, etc. as explained in step one.

Example 1: An ophthalmologist sees a patient and performs an intravitreal injection of Kenalog, 20 mg. You're unaware that the patient is an SNF resident, so you report 67028 (Intravitreal injection of a pharmacologic agent [separate procedure]) for the injection and two units of J3301 (Injection, triamcinolone acetonide, not otherwise specified 10 mg) for Kenalog.

If the patient is an SNF resident, covered by Medicare Part A, the carrier will likely deny reimbursement for the drug. For an SNF patient in this scenario, you should report 67028 to the Medicare Part B carrier, and the cost of the medication (two units of J3301) to the SNF.

Example 2: Using a handheld fundus camera, the ophthalmologist takes fundus photographs of an SNF patient. Submit a claim to your Medicare Part B carrier for the professional component of the fundus photography, using CPT code 92250-26 (Fundus photography with interpretation and report; professional component). Submit a claim to the SNF with 92250-TC (... technical component).