Practice Management Alert

Follow these tips when seeing SNF patients to ensure payment.

Many specialty practices see a skilled nursing facility (SNF) patient on occasion, and while the visit may not stand out in terms of patient care, the billing aspects can be very different from other patient situations.

The government requires SNFs to “consolidate” their billing for Medicare Part A-stay residents, and almost all services are excluded from the prospective payment system (PPS).

Beware: 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.

Nuts and bolts: “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,” Noridian says.

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

Tip 1: Know Which Patients Are in SNFs

The first step in consolidated billing is to develop a system to identify which of your patients are Medicare Part A beneficiaries who live in SNFs. Although this seems obvious, it can be overlooked.

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 having a plan and protocol in place where all patients are asked whether they live can prevent a lot of headaches later when your billing team is trying to sort out who is responsible to pay for what.

Tip 2: Know Which Services Are Consolidated

Some specialty services, such as a pulmonologist’s professional services, are excluded from the consolidated billing requirement 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: Simplify Matters With a Contract

Develop a one-page contract for you to use with SNFs — this is helpful in situations where your physician is seeing a SNF patient in the office, as well as when she goes 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 on page XX).

While a contract may not always eliminate problems, it gives you the legal boundaries to deal with payment issues, as well as setting up expectations up front.

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.

Examine This Scenario

A 68-year-old Medicare beneficiary who has been followed by a pulmonologist for emphysema presents to the office for evaluation of increasing episodes of wheezing. The pulmonologist is aware that the patient is receiving a short course of inpatient Part A skilled nursing facility care following a three-day hospitalization for uncontrolled diabetes mellitus and influenza with pneumonia.

The doctor orders a chest x-ray and pulse oximetry in the office. The chest x-ray is normal, and the pulse oximetry is 92 percent. He performs a focused exam, noting obvious wheezing upon chest auscultation. The pulmonologist asks the nurse to administer a nebulizer treatment for acute airway obstruction. The patient’s color improves following the treatment.

The pulmonologist 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 pulmonary physician bills the SNF for the following services:

• The technical component of the x-ray, if she owned »»the equipment.
• The nebulizer treatment, which is considered »respiratory therapy and covered by the SNF PPS. (No modifier is needed.)

The pulmonologist will receive reimbursement for the evaluation and management (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.