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Urology Coding Alert

SNFs Can Snuff Your Pay if You Dont Know the Ropes

Published on Tue Jul 01, 2003

If you think worrying about skilled nursing facility (SNF) patients is something only the billing department needs to do, think again a patient's SNF status determines how you code your urologist's services.

 If a patient is considered an occupant of an SNF bed and you don't know this when you file the claim, you could owe Medicare a refund. CMS is now on the hunt for reimbursement that physicians shouldn't have received under a provision that hit the books last summer. The provision requires you to separately code the technical and professional components of those procedures that have both components.

 According to CMS, for services with both a professional and technical component, Medicare Part B is only responsible for reimbursing the professional component of services provided to SNF patients and refund requests are being issued to practices that have submitted claims for the global payment of services to Part B and erroneously received reimbursement. "They're asking for a refund on the technical component because the patients have Part A coverage through their nursing facility," says Lucia Yang, billing specialist in Williamsville, N.Y.

 Translation for physicians: You'll no longer receive payment from Medicare for any procedures or laboratory studies you perform in the office setting for patients sent to you from a skilled nursing facility bed your reimbursement has to come from the SNF. The program only reimburses physicians for professional services provided to these patients.

 Medicare Part B will reimburse E/M services provided in the office, but various procedures, such as cystoscopies, catheter changes, and Lupron/Zoladex injections, are not payable. So if a urologist performs a service with both a professional and a technical component in his office, he will be reimbursed only for the professional component and only if he codes the service with modifier -26 (Professional component). For the technical component, he must seek compensation from the skilled nursing home.

 When Yang inquired about these refund letters, a Medicare representative explained that medical offices are supposed to bill the SNF for the technical component of the patient visit, and bill Medicare for the professional component, she says. Which means you have to submit separate claims to SNFs and Medicare using modifiers -26 and -TC (Technical component).

Don't Owe Medicare Money

 Here's how it works: To be reimbursed for services that have both a technical and professional component, the provider codes the technical component and submits the claim to the SNF which has received increased funding and payments from Medicare Part A for the total care of the patient for the duration of the patient's occupation of an SNF bed. The SNF is responsible for paying the provider for the services rendered the patient, says Petra Reising, CPC, coding specialist for the Urology Group in Fairfield, Ohio. The coder should then report the urologist's professional services with modifier -26 and submit that claim directly to Medicare Part B.

 CMS backs Reising up: Physicians are "required to forward the technical portions of any services to the SNF to be billed by the SNF to the FI for payment. 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."

 Reising identifies important steps to receiving reimbursement for services in their entirety:

 Step 1: Determine whether the patient is considered an SNF resident. To determine this, you need to know three pieces of information: what is considered an SNF, how CMS defines an SNF resident, and when a beneficiary is no longer considered an SNF resident.

 According to CMS Program Memorandum B-00-67, facilities that require consolidated billing of services are participating SNFs and any part of a nursing home that includes a participating distinct, participating SNF. The memorandum defines an SNF resident to be "a beneficiary who is admitted to a Medicare-participating SNF, or to the nonparticipating portion of a nursing home that also includes a Medicare-participation SNF, regardless of whether Part A covers the stay." The SNF resident status is ended when the beneficiary: 

  •   is admitted as an inpatient to a Medicare-participating hospital or critical access hospital, or as a resident to another SNF
     
  •  has been discharged from the SNF and receives services from a Medicare-participating home health agency under a plan of care
     
  •  receives emergency or other excluded outpatient services
     
  •  is formally discharged or otherwise departs from the SNF (If the beneficiary is readmitted or returns to that or another SNF before midnight of the same day, the beneficiary will still be considered to be an SNF resident).

     SNF patients' statuses change all the time. Make sure you've established the patient's status the day of the visit, not one day ahead, because it may change daily, Reising says.

     Step 2: Report the professional and technical components separately. Keep a list of services whose professional and technical components must be billed separately, and check the list before submitting a single global claim for the services the urologist performed. File the claim for the technical component as though the SNF were an insurance carrier, Petra says, putting the name of the facility at the top of the CMS form, and your billing information, place of service, etc., below. Reising proffers a list of some common in-office urology procedures that fall under the SNF coding guidelines:

  •  All urodynamics codes including 51785 (Needle electromyography studies [EMG] of anal or urethral sphincter, any technique), 51795 (Voiding pressure studies [VP]; bladder voiding pressure, any technique) and 51797 ( intra-abdominal voiding pressure [AP] [rectal, gastric, intraperitoneal])
     
  •  Computed tomography scan codes: 74150-74170 for abdominal scans, 72192-72194 for pelvic scans, and 71250-71270 for chest scans
     
  •  Lab/urinalysis codes 81000 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy) and 81002 ( non-automated, without microscopy)
     
  •  All chemotherapy drug supply codes, including J9201 for Gemzar, J9291 for Mutamycin, J9340 for Thioplex, and J9217 for Lupron
     
  •  Biofeedback codes 90901 (Biofeedback training by any modality) and 90911 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry)
     
  •  General procedures of the integumentary system (10060, 11040-11043, 17000-17004, 17110 and 17250)
     
  •  Dilation services codes 53660* (Dilation of female urethra including suppository and/or instillation; initial) and 53661* ( subsequent)
     
  •  Catheterization codes 51701 (Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]), 51702 (Insertion of temporary indwelling bladder catheter; simple [e.g., Foley]) and 51703 ( complicated [e.g., altered anatomy, fractured catheter/balloon])
     
  •  Pessary procedure code 57160* (Fitting and insertion of pessary or other intravaginal support device).

    •  Step 3: Fight for reimbursement from the SNF. It's not always easy to get the SNF to pay you for your services, even if you've submitted a claim to the facility for technical services you performed for one of its SNF residents. To avoid any payment obstacles, you should draw up a contract that requires the SNF to reimburse you for your technical or other procedural services. Another option is to have your urologist order facility nursing personnel to administer necessary services at the SNF, precluding a visit to the urologist's office for a nonpayable service. An example of this would be an order for "Lupron 7.5 mg IM every month."

     In an emergency, consider taking the SNF resident to the hospital emergency room and performing the necessary services there from this place of service, the global charges for services and procedure may be billed in their entirety to Medicare Part B.

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