Editor’s note: The following content is an excerpt from Consolidated Billing for Long-Term Care by Frosini Rubertino, RN, BSN, C-NE, CDONA/LTC.
Oftentimes, claim rejections and negative outcomes from billing compliance audits are results of ineffective or nonexhaustive processes within the skilled nursing facility (SNF). This article will help providers lay the foundation for a comprehensive billing system that safeguards against these pitfalls by highlighting special consolidated billing (CB) cases whose navigation could otherwise throw a wrench in workflows.
This article reviews special billing cases including physician and nonphysician practitioner services, leave of absence, and chemotherapy administration.
Physician and nonphysician practitioner services
In the past, Medicare Administrative Contractors (MAC) have reported a high volume of overpayments stemming from confusion related to the Medicare rules for SNF consolidated billing when services provided by physicians or qualified nonphysician practitioners (i.e., a physician, physician assistant, nurse practitioner, certified nurse-midwife, qualified psychologist, or certified registered nurse anesthetist) are involved in the care of nursing home residents. (For the purpose of brevity, these providers will often be referred to as “practitioners” throughout the remainder of this article.)
Medicare pays these practitioners for professional services they deliver to beneficiaries during Part A SNF stays (including those that make up only a component of a larger service rendered by the SNF itself) separately under Part B. To that end, certain services, such as x-rays and other lab tests, can involve two elements that are each billed in distinct ways. The professional component of a service centers on the interpretation of the test or exam (and thus on the clinician’s expertise), while the technical component is constituted by the actual performance of the test or exam.
The following examples shed more light on how SNF and practitioner billing intersect:
Chest x-rays are the most common services delivered to beneficiaries during Part A SNF stays that require billable input from both the facility and an outside practitioner.
When a practitioner provides a chest x-ray, frontal and lateral view (Healthcare Common Procedure Coding System [HCPCS] code 71020), to a given beneficiary, his or her office bills Medicare Part B directly for the professional component (i.e., the interpretation of the chest x-ray) using modifier 26 after the HCPCS code (71020-26).
In regard to the service’s technical component, the practitioner office should bill the SNF for this element (i.e., the actual chest x-ray) using the TC modifier (71020-TC). This is the only portion of the test for which the SNF is required to bill Medicare, since the practitioner submits a separate claim for the professional component.
Transportation and setup of portable x-ray equipment
A portable x-ray is a service that involves the transport of necessary equipment to the SNF to facilitate performance of the x-ray in the facility. Similar to the billing process for the provision of a chest x-ray, a practitioner should bill Medicare separately for the professional component of a portable x-ray it renders to a Part A SNF beneficiary, which in this case would be the interpretation of x-ray results.
In line with typical CB requirements and as clarified by the Centers for Medicare & Medicaid Services (CMS) in an April 2015 memo, the technical component of a portable x-ray (i.e., the procedure itself, including any associated transportation and setup costs) is subject to SNF consolidated billing. Consequently, the facility must list all care and costs associated with the technical component of the x-ray on the consolidated bill and pay the actual service renderer (which could differ from the practitioner responsible for the professional component) from the PPS rate payment according to governing regulations and the specific terms laid out in the entities’ established payment arrangement. (See CMS Transmittal 3230, Change Request 8997 for more information.)
Although diagnostic tests do not appear on any list of excluded services—they are reimbursed through the SNF PPS rate and are therefore subject to CB requirements when furnished to a beneficiary during a Part A stay—their completion does require outside practitioner services (i.e., input and evaluation), which are separately billable to Medicare Part B. Therefore, while a SNF must include the technical component of a diagnostic test (i.e., the physical test) on its consolidated bill, the practitioner must bill the Part B carrier separately for the professional component (i.e., interpretation of the results).
Because the SNF will account for the technical component of the diagnostic test on the Part A consolidated bill, the outside entity that furnishes this element will bill the SNF, rather than Part B, for due payment.
Scope of SNF liability for practitioner billing errors related to included services
SNFs should be vigilant when choosing and communicating with outside service partners—especially those that will be responsible for rendering services (in whole or part) to Medicare beneficiaries during Part A stays at their facilities. This is because in the event that a physician or nonphysician practitioner makes a mistake while billing Medicare for such a service, and this error results in an overpayment or outright denial, the SNF is still responsible for reimbursing the entity for the CB-included component(s) of the item.
The following examples illustrate the potential fallout from practitioner billing errors. Although the billing consequences outlined below don’t directly affect SNFs, they could jeopardize facilities’ relationships with outside providers, who may become frustrated by reimbursement setbacks and reluctant to collaborate with SNF partners in the future. SNFs that belong to accountable care organizations may experience more tangible repercussions because of the higher stakes the partnerships face regarding collaboration and benchmark attainment. For these reasons, SNFs should reach out to their practitioner partners on a regular basis to measure the strength of communication practices and identify any educational gaps.
A practitioner office could be overpaid by Medicare for a service the provider rendered to Margaret, a Part A SNF beneficiary, if the following chain of events were to occur:
Before the SNF submits its monthly consolidated bill for Margaret to Medicare Part A, a practitioner bills Medicare Part B for one of the services that will be itemized on the facility’s claim.
However, because the SNF hasn’t actually submitted this claim to Part A yet, Part B is not aware that Margaret is in the midst of a covered Part A stay when the practitioner submits its inappropriate claim. Consequently, Part B reimburses the practitioner for the service.
Later, when the SNF submits its corresponding consolidated bill to Part A, a notification is sent to Part B indicating that Margaret is indeed in the midst of a Part A stay.
Medicare then searches its records for that time period to identify any payments made for services subject to consolidated billing, a process that reveals the prior practitioner reimbursement as an overpayment and triggers Medicare to recoup the extra money from the practitioner’s office.
Practitioner billing denial
If the above-given scenario involved the SNF submitting its consolidated bill for Margaret before the practitioner submitted its overlapping bill, the practitioner would receive notice of an outright claim denial from Medicare.
Here’s an example of what such a situation might look like:
The SNF submits its monthly bill for Margaret to Medicare Part A.
Later, a practitioner bills Medicare Part B for the entire provision of an x-ray, a service whose technical component is subject to consolidated billing. Consequently, Medicare Part B denies the practitioner’s initial claim and reimburses the provider only after it submits a new bill solely for the professional component of the x-ray, the only portion of the service that is excluded from SNF consolidated billing.
At this point, the entity that actually rendered the x-ray (e.g., the practitioner office or another vendor) should bill the SNF for associated costs.
Key takeaways for service collaboration with physicians and other practitioners
It’s essential for SNFs to understand the billing expectations and requirements that outside providers, such as physicians, have regarding the services they render to Medicare beneficiaries during Part A SNF stays. By staying on top of relevant Medicare billing requirements for partners in other settings, as well as remaining knowledgeable about the specific terms of various payment arrangements, facilities can ensure they are being billed and reimbursed fairly and that other service providers are held accountable for their role in SNF consolidated billing.
SNFs should be especially aware of the interplay between their billing practices and those of outside practitioners because of the frequent collaboration between these providers and the complex Medicare requirements that bind them. To that end, the following list summarizes Medicare’s top billing guidelines, stipulations, and program features that affect service provision collaborations between SNFs and qualifying practitioners:
Medicare rules exclude a limited number of services from consolidated billing, such as practitioners’ professional services (including the professional components of certain services rendered in the SNF), which the program pays for separately.
Physicians and other qualified practitioners should not bill Medicare Part B for services included in consolidated billing. They should bill Part B only for services that are excluded from SNF consolidated billing.
Medicare Part B is notified that a beneficiary is enrolled in a covered Part A stay only after Part A receives a CB claim from the SNF for services rendered during this time.
To prevent denials and overpayments related to CB-applicable services, the practitioner should initiate a screening process that includes determining whether a given patient is a resident of a SNF. This process should involve and facilitate communication between the practitioner, the SNF, and any other implicated service providers—a practice that is crucial for compliant billing.
Leave of absence
Identifying the specific effects a beneficiary’s leave of absence (LOA) can have on billing has long been hazy territory for SNFs, which sometimes confuse Medicare’s CB requirements related to this event with internal definitions and policies they’ve developed for a beneficiary’s temporary exit from the facility.
Under CB rules, a beneficiary in the midst of a SNF stay must be present for a midnight census in order for the SNF to bill Medicare for services delivered on the day immediately preceding it. (See the SNF final rule for fiscal year 2001, CFR page 46792.) Therefore, if a beneficiary exits a facility during his or her stay and doesn’t return by the midnight census that caps off the day the LOA was initiated, the facility cannot bill Medicare for that day, even if the absence lasts for less than 24 hours. In this case, the day for which the beneficiary missed the midnight census is considered a “billing leave of absence day,” and is not billable, even if the SNF delivered skilled services sometime during it.
Consider the following two scenarios, which apply some of these concepts to Linda, a beneficiary in the midst of a Part A SNF stay.
Scenario: Linda leaves the facility with her daughter on Monday after lunch to go to the physician’s office for lab work (a service that is typically accounted for on a SNF’s consolidated bill) and stays at her daughter’s house until 10 a.m. on Tuesday.
Analysis: Because Linda was not back in time for the midnight census that closed out Monday night, the SNF is not responsible for billing the lab services she received from the physician on Monday. Therefore, the facility should not bill Medicare for that day, as SNF consolidated billing applies only to Part A payable days.
Scenario: Linda leaves the SNF with her daughter on Monday after lunch and stays at her daughter’s house until 10 a.m. on Tuesday. An hour before this return to the SNF, Linda’s daughter takes her to the physician’s office for lab work.
Analysis: The timing of this decision renders the SNF responsible for billing Medicare for the lab services because Linda was in the facility for the midnight census on Tuesday night. Therefore, the SNF is responsible for including all the lab costs incurred Tuesday on the Part A consolidated bill.
Over the course of their billing research and compliance efforts, Medicare providers have probably noticed that the MAC Update includes an asterisk (*) next to certain chemotherapy administration codes.
In the SNF sector, this symbol indicates which services are included in the SNF PPS payment (i.e., on the consolidated bill) for beneficiaries who are in the midst of a Part A stay when the associated services are performed alone or with other surgery. However, these items are excluded from the SNF consolidated bill if they have the same line item date of service (LIDOS) as an excluded chemotherapy drug, in which case the provider would bill Medicare on a separate (i.e., non-CB) claim that lists both services.
Before submitting a claim to Medicare for these excluded services, SNFs must first verify that physician orders exist to support the provision of chemotherapy to avoid receiving a denial when they bill for the administration on the same claim.
The drug “pralatrex injection, 1 milligram” (HCPCS code J9307) is excluded for a beneficiary in the midst of a Part A stay, meaning the administration of this medication is also excluded, and the physician (rather than the SNF) must bill for both the drug and the administration on a separate claim instead of the consolidated bill.
In contrast, if a beneficiary is prescribed a medication that is included in consolidated billing, the SNF must also include its administration on the consolidated bill.
Chemotherapy codes that are listed with a caret (^) represent services that receive no Medicare payment. Instead, they are bundled with other rehabilitation services and may also be bundled with any therapy code.
Asterisks hold additional meaning for hospital providers. SNFs that render chemotherapy services to their Part A residents must always bill for chemotherapy administration together with the administered drug, regardless of whether the service is included in (i.e., asterisked) or excluded from CB. However, for hospitals (including CAHs), the lack of an asterisk next to a certain administration code represents an excluded service for which these specific entities can submit a claim without also billing for a corresponding chemotherapy drug.