Ophthalmology and Optometry Coding Alert

Seeing SNF patients can lead to payment hurdles if you don’t know the rules.

Almost every ophthalmology practice sees a skilled nursing facility (SNF) patient now and then – and although those visits are not usually all that different from standard patient encounters, they can be vastly different when it comes to the billing rules.

That’s because the government requires SNFs to “consolidate” their billing for Medicare Part A-stay residents, and all but a few services are excluded from the prospective payment system (PPS). Physicians who bill Medicare for services that are part of the all-inclusive PPS rate could be setting themselves up for payment recoupments and potential fraud and abuse investigations.

In black and white: “For services and supplies furnished to a SNF resident covered under the Part A benefit, SNFs are not able to unbundle services to an outside provider of services or supplies that can then submit a separate bill directly to Medicare,” says Part B MAC Noridian Medicare on its website. “Instead, the SNF must furnish the services or supplies either directly or under an arrangement with an outside provider. The SNF, rather than the provider of the service or supplies, bills Medicare. Medicare does not pay amounts that are due to a provider of the services or supplies to any other entity under assignment, power of attorney, or any other direct payment arrangement. As a result, the outside supplier of the service or supplies must look to the SNF, rather than to the beneficiary or Medicare, for payment.”

To ensure that you’re reporting your services for SNF patients accurately, check out these three quick tips.

Tip 1: Identify These Patients

The first step in consolidated billing is to develop a system to identify Part A SNF-stay patients seen in the office. This may sound like a no-brainer, but much of the time it can be overlooked or missed.

Many SNFs send a form or notice to the physician’s office with the Part A-stay patient instructing the physician’s office to bill the SNF for services that are subject to consolidated billing. However, this step doesn’t always happen, and it’s up to you to find out when a patient is actually a SNF resident. They may be brought to your office by SNF staff, or they could present with a family member. So it’s up to your practice to get this information up front.    

Tip 2: Know What’s Included

The ophthalmologist’s professional services are excluded from the Consolidated Billing rule and are therefore separately payable, according to a CMS Fact Sheet on Consolidated Billing, which was last updated in June 2018. However, if the doctor performs a diagnostic test in addition to the visit, the technical portion of the diagnostic test does fall under the Part A consolidated billing rules. That’s when things get confusing, because payment for those line items will be sent to the SNF and not to your office.

Tip 3: Create A Contract

Develop a one-page contract for you to use with SNFs– this is helpful whether your physician is seeing a SNF patient in the office or if he is going to the SNF to treat patients there. The contract should list the physician’s billing information and include a disclaimer stating that you expect payment for services rendered regardless of the SNF’s reimbursement status with the Medicare carrier (see sample contract in sidebar).  

While a contract may not always eliminate problems, it gives you the legal boundaries to deal with payment issues.

Charge SNFs only for the reimbursement you could expect according to the Medicare fee schedule. You can’t tack on fees to account for driving time or gas costs related to SNF visits, even if you think you deserve pay for this.

Tip 4: Check This Example

A 72-year-old Medicare beneficiary who has been followed by the ophthalmologist for retinopathy presents from the SNF to your office. An ophthalmologist sees a patient and performs a level three office visit, as well as taking fundus photographs.

In this case, you’ll submit a claim to your Medicare Part B carrier for the E/M service and the professional component of the fundus photography, using CPT^® code 92250-26 (Fundus photography with interpretation and report; professional component). However, you’ll submit a claim to the SNF with 92250-TC (... technical component).