Orthopedic Coding Alert

When billing for skilled nursing facility (SNF) patients who present to your orthopedic practice for x-rays, you should bill the physician's x-ray interpretation to Medicare with modifier -26 (Professional component) appended, but you must bill the technical component (the radiology clinician's portion) directly to the SNF.

The Balanced Budget Act of 1997 requires SNFs to consolidate their billing for Medicare Part A residents, which means that orthopedists who bill the global x-ray service directly to Medicare for these patients will receive denials. CMS Program Memorandum B-00-67 states, "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."

"Medicare's rationale for the x-ray denials is that they believe the x-rays should actually be performed in the SNF, so they're not going to pay us for the service," says Jackie Gotsch, biller at Housatonic Orthopaedic and Sports, a three-orthopedist practice in Ansonia, Conn.

Don't wait until an SNF patient presents for her appointment before you think about how to code her service. When the SNF calls to schedule the x-ray, the receptionist should note the patient's fee ticket to ensure that the coder knows the patient resides in an SNF.

"When the fee ticket gets to the coder, he or she should create another, separate fee ticket," says Deb Hudson, CCS-P, coder at the Mason City Clinic, a 35-physician multispecialty practice in Iowa. "The fee ticket for professional services will go to the patient's Medicare Part B carrier, and the other fee ticket, for technical services, is billed to the SNF with modifier -TC (Technical component)."

Hudson suggests setting up separate accounts for the various SNFs in your area so the information is sent to the appropriate party at the nursing facility for reimbursement. Hudson says that this process has worked well for her practice, and she reminds coders to include the SNF "OSCAR" number (which identifies the facility) on all claims for SNF patients.

Paula Roland, office manager for Michael J. Pushkarewicz, MD, an orthopedist in West Grove, Pa., reminds coders that you can still bill SNF patients' E/M visits directly to Medicare.

Suppose a patient recovering in an SNF after surgery to repair a hip fracture (733.14) presents to her orthopedist for a follow-up visit, where the practice's radiology technician x-rays two views of the patient's hip (73510). The orthopedist reads the x-rays and writes his report, then examines the patient during a level-three E/M service.

The coder should submit the following claim to the patient's Medicare carrier: