Urology Coding Alert

Not knowing which services are covered will cost you time and money

If you're not paying attention to consolidated billing regulations, you could be putting your practice at risk for frequent lost payments and even auditing. If your urologist treats patients in skilled nursing facilities, here's how to ensure you don't end up sacrificing a portion of your fees.

Make Sure You're Dealing With a SNF

A patient's skilled nursing facility (SNF) status determines how you should be coding and billing for your physician's services, and if you're not following consolidated billing rules you'll continue to sacrifice part of your fees.

The problem: Billing is complicated for patients in SNF care, but not all nursing facilities are SNFs, says Carol Pohlig, BSN, RN, CPC, ASC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. A SNF may not even be an entire facility--some facilities have SNF beds and non-SNF beds.

"Even more difficult is what visits physicians can report for the SNF patients," Pohlig adds. 

First step: Call the facility to confirm that the patient is in SNF care. If he is not, you may bill your Part B carrier for all the services you provide. But if he is a SNF patient, you are about to enter the world of consolidated billing.

Because Medicare Part A typically covers SNF patients and consolidated billing rules apply, you can report only certain services to Medicare. Whether the physician visits the SNF or the SNF patient visits your office, if the patient is in a covered Part A stay, the SNF rules still apply and the facility is liable for the payment.

Exceptions: Medicare has made things a little more complex by excluding physicians' services (E/M) and the professional components of certain diagnostic services from the consolidated billing requirement. Medicare sees these as outside the SNF bundle and says that "they remain separately billable to Part B when furnished to a SNF resident by an outside supplier."

Leave the Professional Portion to Medicare

CMS regulations state that for services with both a technical and a professional component, you should report only the professional component to Medicare. You should then bill the SNF directly for the technical component.

And for many of the medications your physician might administer (with the exception of some chemotherapy drugs--not including LHRH analog therapies, which are consolidated), Medicare Part B will not reimburse you in the usual manner. Instead, you must submit a claim to, and seek payment from, the SNF itself.

Note: Don't be surprised if the nursing facility requires a contract. Because of Medicare Part A requirements, the SNF needs to have a set contract with you to gain reimbursement for the technical portion of the professional service your urologist provides. 

Good news: CMS has outlined some exclusions to these billing rules, Pohlig says. You can report any services that appear on the exclusion list to Medicare Part B directly, even if it is has a technical component to it.

Conquer Nonpayment With 4 Steps

Consolidated billing denies your office direct control over the quality of billing and reimbursement.

Consequently, SNFs with less-than-optimal billing operations can come up short of money and try to deny you payment. It's not fair or legal for a SNF to tell providers they'll be paid only when and if the SNF receives adequate payment.

Follow these expert suggestions to make consolidated billing as painless as possible:

• Take a one-page contract with you on SNF visits. The contract should list your 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. You can also consult the CMS Web site (www.cms.hhs.gov/snfpps/08_bestpractices.asp) for several sample SNF contracts.

• Charge SNFs only for the reimbursement you would expect according to the Medicare Physician 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.

• Use a contract and talk first to resolve any persistent payment problems with a SNF. As a last resort, however, you can report your problems to the local or regional overseer of nursing homes and SNFs and request an investigation into their billing operations.

• Consult the CMS Web site or call your Medicare carrier to resolve questions about what services are included and excluded under consolidated billing. Medicare may even be able to send a trainer to your office to advise you on consolidated billing issues.

Bonus: For more information on consolidated billing, visit www.cms.hhs.gov/providers/snfpps/cb/.