Radiology Coding Alert

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

The Balanced Budget Act of 1997 requires SNFs to consolidate their billing for Medicare Part A residents, so if your radiologist is still billing global x-ray service for SNF patients directly to Medicare don't expect more than consistent problems. 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."

Of the more than 11,000 procedures included in Medicare consolidated billing, "any that are considered good old-fashioned basic x-rays including a lot of the nuclear medicine procedures would be billed by the SNF," says Rusti Bauman, RN, BSN, MS, a nurse consultant with FR&R Healthcare Consulting in Deerfield, Ill.

Don't wait until an SNF patient presents for her appointment before you think about how to code the 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. She says 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.

Bauman agrees that you should "red-flag" SNF patients right away and reminds coders that you can still bill SNF patients' E/M visits directly to Medicare.

Suppose a SNF patient in a covered Part A stay falls and the staff doesn't know what happened to her. After the patient fell, her mobility was fine, but today she is complaining of severe pain in the tailbone and demonstrates a change in level of consciousness. An x-ray of the coccyx would be included in the Part A bill. She presents to the outpatient radiology department of a facility, where the radiology technician x-rays two views (72220, Radiologic examination, sacrum and coccyx, minimum of two views). The radiologist reads the x-rays and dictates his report.

If the radiology practice has a contract with the SNF, then the coder should send a separate claim directly to the SNF listing 72220-TC as the procedure code and 806.6x (Fracture ... sacrum and coccyx) as the diagnosis.

Remember that you can bill the x-ray's technical component only if your practice owns the x-ray equipment, owns or leases the space where the equipment resides, and pays the salaries of the personnel taking the films, because the -TC modifier's fee includes those technical costs. Therefore, in the office setting, the TC bill would be generated by the practice and would be billed to the SNF.

Radiology billers should also remember the emergency exception, Bauman says: If the patient's injury is life-threatening or very serious, then the hospital ED can bill radiologic services for SNF patients outside of consolidated billing.

The bottom line, Bauman says, is that if you see Part A SNF patients for many routine radiology procedures, and you neglect to bill the nursing home, you're going to lose money.

And closing your books for the month will turn into a nightmare because backtracking to the month before, contacting the patient, and balancing the numbers can cost a lot in staff time, not to mention hard cash. "You could feasibly have a dozen or more procedures that you're going to lose money on," Bauman warns. "One or two procedures may not be worth the effort, but if you get into large numbers, you will want to find who's responsible for paying the bill."

Some services, such as anesthesia and customized prosthetic devices, are not subject to consolidated billing. The CMS Web site www.cms.hhs.gov/medlearn/ snfcode.asp provides a list of these services and the answers to many SNF billing questions.