Otolaryngology Coding Alert

Hint: Use an agreement resembling that of an ABN.

Your otolaryngology practice might come across a skilled nursing facility (SNF) patient every once in a while. While the encounter itself may not differ substantially than that of a standard patient encounter, you’ve got to consider how the billing rules differ.

More specifically, you’ve got to know that 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). This means that 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.

According to Medicare: “For services and supplies furnished to an 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 Medicare Administrative Contractor (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.”

Code your SNF patients accurately and compliantly by utilizing these four helpful 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 or your practice manager to find out when a patient is actually an SNF resident as opposed to a nursing facility patient. (SNF patients and NF patients may be found to be in the same room, as roommates, in the same facility. The only difference is a status of the patient, providing different benefit levels from Medicare.) They may be brought to your office by the nursing home staff, or they could present with a family member. It’s the responsibility of those in your practice to get this information up front.

Tip 2: Know What’s Included

The otolaryngologist’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 billing and payment for those line items have to be sent via the SNF and not to your office.

Tip 3: Create an Agreement

Develop a one-page agreement between you and the nursing facility for SNF patients who may receive diagnostic services from you. This is helpful whether your physician is seeing a SNF patient in the office or if he is going to the nursing facility to treat patients there. The agreement should list the physician’s billing information and include a disclaimer stating that you expect payment for services rendered regardless of the nursing facility’s reimbursement status with the Medicare carrier.

While an agreement may not always eliminate problems, it gives you the legal boundaries to deal with payment issues. This can be prevented by only charging nursing facilities for the reimbursement you could expect according to the Medicare fee schedule.

Tip 4: Check This Example

A 68-year-old Medicare beneficiary who has been followed by the otolaryngologist for chronic laryngitis presents to the office for evaluation of increasing episodes of pain, voice loss, and wheezing. The otolaryngologist is aware that the patient is receiving a short course of inpatient Part A SNF care following a three-day hospitalization for uncontrolled diabetes mellitus and influenza with pneumonia.

After examining the throat and prescribing antibiotics to treat the laryngitis, the provider performs a pulse oximetry in the office. During a focused exam, the provider notes wheezing upon chest auscultation. The otolaryngologist asks the nurse to administer a nebulizer treatment for acute airway obstruction. The patient’s color improves following the treatment.

The otolaryngologist calls the SNF geriatrician to provide an update on the patient’s worsening asthma and suggests nebulizer treatments be provided in the SNF for wheezing episodes. The physician bills for the nebulizer treatment to the nursing facility, which is considered respiratory therapy and covered by the SNF PPS. No modifier is needed.

The otolaryngologist will bill and receive reimbursement for the E/M service directly from the Part B MAC. “The pulse ox is typically bundled into payment for other services billed on the same day, so this should not be billed separately to either the SNF or Medicare Part B,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.