Presented by: Therese DiSilvestro, RN, BSN, MBA Genesis Healthcare Corporation Clinical Reimbursement Manager Regulatory Compliance/Program Development
The information contained herein is of a general nature an is not intended to address the circumstances of any particular individual or entity. Although we endeavor to provide accurate and timely information, there can be no guarantee that such information is accurate as of the date it is received or that it will continue to be accurate in the future. No one should act upon such information without appropriate professional advice after a thorough examination of the particular situation.
The Pennsylvania Association of Nurse Assessment Coordinators Education Committee has identified there are no conflicts of interest of the speakers in the presentation of this educational program.
To provide a basic level of understanding of what CB means to a SNF and how it can impact reimbursement Review key terminology Provide a general explanation major categories for SNF consolidated billing Provide a brief review of the Consolidated Billing process within the SNF
This billing requirement obligates the SNF to bill Medicare for the entire package of services that a facility resident receives (except for specifically excluded services that are considered separately payable) The SNF must look to its global per diem payment to cover the costs of the services rendered.
The SNF, rather than the provider of the item or service, bills the FI or A/B MAC for all services that are subject to CB. As a result, the outside provider or supplier of these services or supplies must look to the SNF, rather than to Medicare for payment.
Most covered services and supplies furnished to a resident of a SNF in a covered Part A stay, including those furnished under arrangement with an outside provider, are included in the SNF's bill to the FI or A/B MAC. The SNF may collect any applicable deductibles, coinsurance, and copayments from the resident
Part A covered services, whether provided directly by the SNF, under arrangement, or incident to physician professional services, include: Nursing services; Physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP) services; Drugs, biologicals, supplies, appliances, and equipment; Enteral and parenteral nutrition; Labs and x ray services; Ambulance services unless excluded; Orthotics; Prosthetics unless excluded; Any service received in an emergency room that is not for emergency treatment; and Room and board and all ancillary services.
Please note that when a beneficiary no longer requires a skilled level of care or exhausts his or her 100 days (i.e., he or she is in a non-covered stay), he or she may still be a resident in the SNF. If this occurs, the beneficiary would then be responsible for the room and board charges; however, once the beneficiary enters a noncovered stay, Medicare may pay for certain ancillary services that are covered under the applicable Part B benefit if the beneficiary has Medicare Part B eligibility.
When the beneficiary no longer has Part A coverage in the SNF, the rules for CB change. At that time, the only services still subject to CB are therapy services (i.e., PT, OT, and SLP).
When a beneficiary resides in a nursing home (or part thereof) that is not certified as a SNF by Medicare, the Part A extended care benefit cannot cover the beneficiary s stay. However, the beneficiary may still be eligible for Part B coverage of certain individual services, including therapy. In this case, the beneficiary is not considered a SNF resident for Medicare billing purposes and the therapy services are not subject to CB. Either the therapy provider or the facility may submit a Part B bill for the services
Prior to the Balanced Budget Act of 1997 (BBA), a SNF could elect to furnish services to a resident in a covered Part A stay either: Directly, using its own resources Through the SNF s transfer agreement hospital Under arrangement with an independent therapist (for PT, OT, ST services)
The SNF also had the further option of unbundling a service altogether. In other words, the SNF could permit an outside supplier to furnish the service directly to the resident and the outside supplier would submit a bill to Medicare Part B, without any involvement of the SNF itself.
This practice created several problems: A potential for duplicate billing An increased out-of-pocket liability by the beneficiary for the Part B deductible and coinsurance even if only the supplier billed Created a dispersal of responsibility for resident care which adversely affected quality of care and program integrity (documented in reports by the OIG and the GAO).
Under the consolidated billing requirement, the SNF is responsible to bill for the entire package of care that a resident receives during a covered Part A SNF and for rehab services (PT,OT,ST) received during a noncovered stay with the exception of a limited number of services that are specifically excluded from consolidated billing.
The law describes CB in terms of services furnished to a SNF resident while in a Part A stay. Whenever a beneficiary leaves the facility, his or her status as a SNF resident, for CB purposes (along with the SNF's responsibility to furnish or make arrangements for needed services), ends when one of the following events occur: Resident is admitted to a hospital or CAH Resident formally discharges from the center Resident receives certain outpatient services at a hospital or CAH that are exceptionally intensive
SNFs are not the only provider type affected by CB. SNF CB affects various health care providers that furnish services to SNF residents. Some providers that have the potential to be affected by CB include, but are not limited to, the following: Suppliers; Physicians; Hospital swing beds; Imaging centers; Ambulance suppliers; Hospitals/CAHs; and Radiology centers
The easiest way to eliminate any claim or billing related problems is to communicate with your patients and the providers that service your patients.
Services not included in Skilled Nursing Facility Consolidated Billing are called excluded services. The term excluded usually means that the services are excluded from Medicare coverage (i.e., not covered by Medicare). However, for SNF CB excluded means that these services are separately reimbursable under Medicare Part B rather than being bundled into the SNF s comprehensive Prospective Payment System per diem payment for the covered Part A stay.
Professional Services are excluded and can be billed independently by the provider of the service: Physicians Physician Assistants Nurse Practitioners Certified Nurse Midwife Qualified Psychologist Certified Nurse Anesthetist
Defined as those services that are furnished incident to physician professional services in the physician s office.
While SNF CB excludes the professional services that the physician performs personally, the exclusion does not apply to physician incident to services furnished by someone else as an incident to the physician s professional service. These incident to services furnished by others to SNF residents are subject to CB and, accordingly, must be billed to Medicare by the SNF itself
Incident to services can also be ordered and supervised by certain non physician practitioners such as physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, or clinical psychologists. These services are subject to SNF CB in the same manner as physician supervised services.
Must be an integral part of the patient s course of treatment It is a service that is commonly rendered without charge or included in the physician s bill It is of the type that is commonly furnished in a physician s office It is an expense to the provider It is furnished under the direct supervision of the physician
Examples of incident to services include providing non self administrable drugs and other biologicals and supplies usually furnished by the physician in the course of performing his or her services (e.g., gauze, ointments, bandages, and oxygen). All incident to requirements can be found in Chapter 15, Section 60, of the Medicare Benefit Policy Manual (Pub. 100 02).
Home dialysis and institutional dialysis that meet the requirements for separate coverage under the Part B dialysis benefit are excluded from SNF CB. As such, these services can be furnished and billed directly to the Carrier or A/B MAC by the outside dialysis supplier or to the FI or A/B MAC by the End Stage Renal Disease (ESRD) provider. Erythropoietin (EPO) and Darbepoetin Alfa are excluded from SNF CB and are separately covered under the Part B ESRD benefit for beneficiaries when medically reasonable and necessary for care related to permanent kidney failure.
Services that fall outside the scope of the Part B dialysis benefit do not qualify for the dialysis exclusion from SNF CB. For example, the exclusion does not encompass acute dialysis, which involves patients who do not have ESRD but require dialysis temporarily while their kidneys have shut down following a severe medical trauma. Therefore, acute dialysis would be included in the SNF s global per diem payment.
Hospice care and services are excluded from CB for Part A residents who are in the SNF for other, non-hospice services that are in no way related to the terminal condition. For example, a beneficiary with terminal gastrointestinal cancer tripped over some furniture at home and broke his leg. After a qualifying stay at the hospital, it is determined the beneficiary requires post acute, or SNF, care for rehabilitation of the leg. Instances of such cases may be rare. In order for the beneficiary to qualify for both palliative hospice care and skilled treatment in the above case, the broken leg could not be related to the terminal condition (such as bone metastasis or sedation for the terminal condition).
Certain outpatient services are only excluded when provided in a hospital or Critical Access Hospital (CAH). These administrative exclusions were designed specifically to exclude services that require the intensity of the hospital setting in order to be furnished safely and effectively. This is a very important point that is sometimes overlooked
Cardiac Catheterizations Computerized axial tomography scans MRI services Ambulatory Surgery that requires the use of an Operating Room (or comparable setting) Emergency Services Radiation Therapy Angiography Certain lymphatic or venous procedures Medically necessary ambulance transport for the above services. ***Remember these services must be provided in a hospital setting or equivalent***
Many diagnostic tests have two components: Technical Component the test itself the test is subject to consolidated billing Professional Component represents the physician s interpretation of the test. the physician service exclusion only applies to the Professional Component
Ambulance services are not a type of service that is categorically excluded from Part A CB. Certain types of ambulance transportation have been identified as being separately billable in specific situations (i.e., based on the reason the ambulance service is needed)
Other Ambulance Trips when a beneficiary leaves the SNF to receive offsite services other than the excluded types of outpatient hospital services, the ambulance services furnished in connection with the outpatient visit are subject to CB. Even if the purpose of the trip is to receive a particular type of service that is, itself, categorically excluded (such as physician services), the ambulance trip is still the responsibility of the SNF.
Transfers Between Two Skilled Nursing Facilities A beneficiary s departure from a SNF is not considered to be a final departure for CB purposes if he or she is readmitted to that or another SNF by midnight of the same day. Thus, when a beneficiary travels directly from SNF 1 and is admitted to SNF 2 by midnight of the same day, that day is a covered Part A day for the beneficiary to which CB applies. Accordingly, the ambulance trip that conveys the beneficiary is bundled back to SNF 1, as the beneficiary continues to be considered a resident of SNF 1 for CB purposes up until the actual point of admission to SNF 2.
Roundtrip to a Physician s Office If a SNF s Part A resident requires transportation to a physician s office and meets the general medical necessity requirements for transport by ambulance (i.e., the resident s condition is such that transportation by any other means would be medically contraindicated), then the ambulance trip is the responsibility of the SNF and is included in the PPS rate.
Except for the specific exclusions discussed previously, SNF CB includes those medically necessary ambulance trips that are furnished to or from a diagnostic or therapeutic site during the course of a covered Part A stay. For example, ambulance transports to or from Independent Diagnostic Testing Facilities are considered paid in the SNF PPS rate and may not be billed as Part B services to the Carrier or A/B MAC.
In contrast to the ambulance coverage described previously, Medicare simply does not provide any coverage at all under Part A or Part B for any nonambulance forms of transportation, such as ambulette, wheelchair van, or litter van. Further, as noted in the preceding section, in order for the Part A SNF benefit to cover transportation via ambulance, the regulations at 42 CFR 409.27(c) specify that the ambulance transportation must be medically necessary that is, that the patient s condition is such that transportation by any other means would be medically contraindicated.
As with any non covered service for which a resident may be financially liable, the SNF must provide appropriate notification to the resident under the regulations at 42 CFR 483.10(b)(6), which require Medicare participating SNFs to.. inform each resident before, or at the time of admission, and periodically during the resident s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility s per diem rate.
This means that in a situation where it is medically feasible to transport an SNF resident by means other than an ambulance. For example, via wheelchair van the wheelchair van would not be covered (because Medicare does not cover any nonambulance forms of transportation), and an ambulance also would not be covered (because the use of an ambulance in such a situation would not be medically necessary).
Initial ambulance trip to the SNF for admission Trip home after formal discharge from the SNF Trip to hospital for inpatient admission Trip to hospital to receive emergency services or other outpatient services that are excluded Trip to and from dialysis center for the purpose of receiving Part B dialysis services. ***Remember, the ambulance services are only excluded for the above services if the services are determined to be medically necessary for the patient in a Part A stay
Trip to physician s office Trip from one SNF to another SNF Trips to Independent Diagnostic Testing Facilities Transportation provided by any means other than ambulance:
They are subject to Consolidated Billing but They are not included in the SNF s daily PPS rate, rather they are billed separately under Part B. The SNF is responsible to bill the service.
When an orthotic or prosthetic device is ordered while a beneficiary is in the hospital or at home and the device is not delivered until after the beneficiary has moved to the SNF, the issue arises as to who is responsible for billing the item to Medicare.
Who Pays? The Facility in which the medical need occurred is responsible for billing the device If the device became medically necessary while in the hospital hospital bills Medicare If the devices became medically necessary while home and then patient enters SNF, the provider of device will bill Medicare If the device became medically necessary after the patient enters the SNF SNF bills Medicare unless it specifically excluded from CB.
These additional exclusions apply only to certain specified, individual services within a number of broader service categories that otherwise remain subject to CB Within the affected service categories, the exclusion applies only to those individual services that are specifically identified by HCPCS code.
Certain Chemotherapy items and their administration (applies solely to the particular chemotherapy codes designated under Major Category III) Certain Radioisotope services Customized Prosthetic Devices ***Please note: within these categories, any other service that is not specifically identified by a HCPCS code as excluded, remain subject to CB.
Healthcare Common Procedure Coding System also known as the HCPCS code Enforcement of CB is done through editing Medicare claims using the list of HCPCS Medicare systems must edit for both included and excluded services The list of HCPCS codes is updated by CMS quarterly beginning in January The first quarter is the only quarter in which new permanent HCPCS codes are produced
All procedures have HCPCS codes The HCPCS code MUST first be identified in order to know if the procedure is included or excluded. There are thousands of HCPCS codes!!! The person performing the procedure would be the best person to give the HCPCS code CMS has divided the codes into 5 major categories
Exclusions beyond the scope of a SNF Must be provided in a hospital setting or CAH (critical access hospital) Further broken down into subcategories: A. Computerized Axial Tomography (CT) Scans B. Cardiac Catheterization C. Magnetic Resonance Imaging (MRIs) D. Radiation Therapy E. Angiography, Lymphatic, Venous and Related Procedures F. Outpatient Surgery and Related Procedures G. Emergency Services H. Certain Ambulance Services
Additional services excluded when rendered to specific beneficiaries: ESRD (service must be provided in a renal dialysis facility) Beneficiaries who have elected Hospice
Additional excluded services rendered by certified providers These services may be provided by any Medicare provider licensed to provide them (except the SNF) Include: Certain Chemotherapy drugs Certain Chemotherapy administrations Certain radioisotopes and their Administration Customized prosthetic devices
Additional Excluded Preventative and Screening Services These services are covered as Part B benefits They are not included in the SNF PPS They are billed separately
Includes: A. Mammography B. Vaccines (Pneumococcal, Flu or Hepatitis B) C. Vaccine Administration D. Screening Pap Smear and Pelvic Exams E. Colorectal Screening Services F. Prostate Cancer Screening G. Glaucoma Screening H. Diabetic Screening I. Cardiovascular Screening J. Initial Preventative Physical Exam K. Abdominal Aortic Aneurysms (AAA) Screening
Part B services included in SNF Consolidated Billing If the patient does not qualify for coverage under Part A, the rules for CB change. The patient may still be eligible for coverage of individual services under Part B (this is voluntary medical insurance). Examples include: Physician services PT, OT, ST services Diagnostic Tests
SNF should notify providers and suppliers that the patient is in a Part A stay and they need to look to the SNF for payment of these services. SNF should inform the patient about CB requirements upon admission and upon discharge. SNF is also responsible to ensure that the outside services being provided meets the applicable standards for that service
Varies among companies At the very least: Assist in helping IDT team understand the basics of Consolidated Billing Be aware of the impact that Consolidated Billing can have on reimbursement
If the patient does not qualify for coverage under Part A, the rules for CB change. The patient may still be eligible for coverage of individual services under Part B (this is voluntary medical insurance). Examples include: Physician services PT, OT, ST services Diagnostic Tests
WWW.CMS.gov/Medicare/Medicare-Fee-for- Service-Payment/SNFPPS/ConsolidatedBilling MLN Matters #SE0507 MLN Matters #SE0441 Medicare Claims Processing Manual