Wiki SNF consolidated billing from office perspective (x-post Medicare Regulations)

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j.monday7814

j.monday7814

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I need help regarding final claim submission to Medicare for professional services to a patient admitted to SNF.

I have searched as much as I can and I cannot find any definitive information regarding correct billing. Our original claims were submitted with POS 11 and at first they were paid. Then a few months later Medicare recouped the payment stating the patient was enrolled in SNF. So, I need answers with supporting guidelines from any payer (preferably Noridian or CMS) please.

typical scenario: patient is enrolled in SNF (as inpatient) and comes to our office to see the physician (typically a specialist, i.e. cardio, general surgery, vascular, etc.). We bill Medicare with POS 11 (office, because that is where the patient was seen).

We're stuck on the POS because about a year ago another coder in the office researched this issue and created a policy to change the POS to 31 (SNF because that is where they are currently admitted). The E/M is also changed to a corresponding inpatient code. I feel very uncomfortable billing these out, I can't justify billing an incorrect POS. This new policy does allow claims to be paid but I still don't think it is appropriate billing. Please help us sort this out.
 
Hi Suzanne. Thanks for your help and I actually read that thread yesterday but it didn't provide a definitive answer. Several people posted that it was appropriate to bill the office visit with POS 31 (SNF), but then the very last post was confirmation that POS 11 is correct and they were able to get paid on that.
 
Snf

Billing with pos 31 and using the nursing home codes is the correct way to bill for the professional services.
Medicare Claims Processing Manual 20.1.1.1 - Correct Place of Service (POS) Code for SNF Claims
(Rev. 1, 10-01-03)
Per chapter 26, of this manual, POS code 31 should be used with services for patients in a Part A covered stay and POS code 32 should be used with services for beneficiaries in a noncovered stay. Carriers should adjust their prepayment procedure edits as appropriate.

Chapter 26
Special Considerations for Services Furnished to Registered Inpatients
When a physician/practitioner furnishes services to a registered inpatient, payment is made under the PFS at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. In other words, reporting the inpatient hospital POS code 21 is a minimum requirement for purposes of triggering the facility payment under the PFS when services are provided to a registered inpatient. If the physician/practitioner is aware of the exact setting the beneficiary is a registered inpatient, the appropriate inpatient POS code may be reported consistent with the code list annotated in this section (instead of POS 21). For example, a physician/practitioner may use POS 31, for a patient in a SNF receiving inpatient skilled nursing care, POS 51, for a patient registered in a Psychiatric Inpatient Facility, and POS 61 for patients registered in a Comprehensive Inpatient Rehabilitation Facility.


LeeAnn
 
Hi LeeAnn,

those policies don't apply to this situation. those address when a provider goes to the SNF to see the patient and we don't have any issues getting those claims paid. The problem is when the patient is enrolled in SNF and comes into our office to be seen. In that case it would not be appropriate to bill it with POS 31 since the patient is face-to-face in POS 11. Also, the POS were partially set up to differentiate between facility and non-facility payments. So if we bill these in office visits with POS 31 then we'll only receive facility payments which is less than non-facility.
 
SNF Consolidated billing for some procedures

Hi, i do multi-specialty billing and for our wound clinic patients, the E&M gets paid when billed, but the debridement codes get denied. Reason is the 97597/98 are considered physical therapy codes and are subject to CB billing. We have to then bill the SNF for those codes. I think there are some cardi procedures too that fall under those guidelines.

A problem exists though as per guidelines, we are to have an agreement of sort between physician and SNF stating they will pay. Our supervsr seems to think one doesnt exist, so i dont have much ground to appeal for non-payment. We rebill with printout from NGS re CB and hope for best.

There is great info on theNGS site, search CB, for info. But again, if pt is coming in for cough or something and only E&M, we get paid.

Hope that helps.
 
thanks Birdie625, that is definitely helpful. I'll check out NGS and see what else I can find, thanks again!
 
Snf

Actually those guidelines do apply. They apply when an inpatient, either acute hospital or SNF go to a physician office for an appointment. When these types of patients are seen in a physician office they are billed with the place of service that applies to their inpatient status.
 
Snf

Also, yes you will only get the facility reimbursement even though you are seeing the patient in your office. That is why if you are performing a procedure or other encounter that has a technical and professional component the technical component is billed to the SNF because the SNF is getting paid for the patient to be an inpatient. Medicare will not pay two different entities a facility fee when a patient is inpatient status.

LeeAnn
 
cheermom68 said:
Also, yes you will only get the facility reimbursement even though you are seeing the patient in your office. That is why if you are performing a procedure or other encounter that has a technical and professional component the technical component is billed to the SNF because the SNF is getting paid for the patient to be an inpatient. Medicare will not pay two different entities a facility fee when a patient is inpatient status.

LeeAnn
Click to expand...

this is not correct, Medicare has never asked for the POS to be different from where the patient is being seen. Based on your info if the patient is seen in the office and we bill the claim with POS 31 then we are incorrectly telling Medicare that the patient was physically in the SNF when we saw them. If that were true then how would Medicare know the difference on the claim level if the patient was seen in the office or the SNF....they wouldn't be able to see a difference.

We reconnected with our MAC and their latest info states all physician services performed in the office must be billed directly to the SNF. This didn't sound correct since physician services are supposed to be excluded from consolidated billing but he was quite adamant about that and went on to say that no matter how we bill a claim to Medicare for a patient seen in the office it will not be paid by Medicare.
 
Snf

We are going to have to agree to disagree on this one as I stand by my previous posts. It is similar to if a patient is in an inpatient status and they are wheeled over to your office, you would bill with the inpatient place of service 21 with inpatient codes. the guidelines that I provided previously clearly state that if a patient is inpatient status in any form (rehab, acute care, SNF) and they present to a physician office, the professional fees are billed with place of service for whatever status they are inpatient, 21, SNF, 31 or 32, etc.


LeeAnn
 
snf

Also, Medicare knows the difference because even though the place of service is inpatient SNF, the facility address is where the patient was physically seen, so the office address.

LeeAnn
 
When a physician/practitioner furnishes services to a registered inpatient, payment is made under the PFS at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter.
Click to expand...

I took that from your very first post in this thread. None of this applies to this exact situation, we're not talking about wheeling the patient across the hallway to a physician's office, we're talking about the patient's family/caregiver transporting the patient several miles to the office. I know it would not be correct to report that with POS 31 and it worries me that you do. I don't think this is a situation that can be left to "we'll just agree to disagree" because this situation affects thousands of providers across the country. Medicare would never ask to report a POS that is not correct nor would they purposefully design facility and non-facility payments only to screw us out of any profit when we see a patient enrolled in SNF. That just does not make sense, seeing the patient in the office is more expensive for the practice then seeing the patient in the SNF or hospital which is why we receive higher reimbursement in the office. What logic would there be for them to only pay at the facility rate even though we are incurring all of the expenses which justify the non-facility payment?
 
snf

It is irrelevant how the patient gets to the physician office, the key is that the patient is in an inpatient STATUS somewhere. A very prominent consultant in the Midwest with extensive Medicare background and who sits on the Medicare Provider Outreach and Education committee specifically addressed this during her annual Medicare Seminar, what she states is totally consistent with what I have stated in my previous posts.....
 
but that doesn't allow us to get claims paid and does not coincide with information we received from our MAC. if you have additional reputable sources then please post that information but I haven't found anything on CMS that aligns with your statement.
 
Actually, I provided the resource in my original response.
See Below from the Medicare Claims Processing Manual

Chapter 26
Special Considerations for Services Furnished to Registered Inpatients
When a physician/practitioner furnishes services to a registered inpatient, payment is made under the PFS at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. In other words, reporting the inpatient hospital POS code 21 is a minimum requirement for purposes of triggering the facility payment under the PFS when services are provided to a registered inpatient. If the physician/practitioner is aware of the exact setting the beneficiary is a registered inpatient, the appropriate inpatient POS code may be reported consistent with the code list annotated in this section (instead of POS 21). For example, a physician/practitioner may use POS 31, for a patient in a SNF receiving inpatient skilled nursing care, POS 51, for a patient registered in a Psychiatric Inpatient Facility, and POS 61 for patients registered in a Comprehensive Inpatient Rehabilitation Facility.
 
Cheermom68 is absolutely correct. You use the POS of where the patient is registered as an inpatient. But you use regular office visit codes. The payment is the same as if you saw the patient in the facility. You will be paid and this is the correct billing policy.
 
Hi there -- not sure if you ever got your question answered but I personally always use the office POS when the patient comes to our office from a SNF. I make sure the 26 modifier is on my x-ray's and bill only the xrays to SNF. Then the SNF gets a bill w/ the TC modifier. Exact same claim, just going to two different places.
 
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