Harmony Healthcare Blog

Consolidated Billing in a Skilled Nursing Facility: Top 4 Things to Know

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Tue, Aug 27, 2019
Kris Mastrangelo, OTR/L, LNHA, MBA
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HHI Medicare Denial with the UB-04


Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency

The Balanced Budget Act of 1997 (BBA), Public Law 105-33, Section 4432(b) contains the SNF Consolidated Billing requirements that state the SNF itself must submit all Medicare claims for the services that its residents receive.  Except for specifically excluded services that will be highlighted in this blog post.

  1. Physician Services (Professional Component and Technical Component)

    • (P)-The Professional Component is excluded from Consolidate Billing
    • (T)-The SNF is responsible for the Technical Component. 
    • Certain Diagnostic Tests include both a Professional Component (representing the physician’s interpretation of the test) and a Technical Component (representing the test itself).
    • The technical component is subject to Consolidated Billing. The technical component of these services must be billed to and reimbursed by the SNF.
    • Physician “Incident To” Services
    • While Consolidated Billing excludes the professional services that the practitioner performs personally, the exclusion does not apply to physician “incident to” services furnished by someone else as an “incident to” the practitioner’s professional service.  
    • These “incident to” services furnished by others to SNF residents are subject to Consolidated Billing and, accordingly, must be billed to Medicare by the SNF itself. 
    • Examples of “incident to” services are laboratory tests or x-rays performed in the doctor’s office.
    • Harmony Healthcare International (HHI) recommends incorporating a policy and procedure within the facility that requires the billing hospital to include the Medicare Denial with the UB-04.  This refinement of the policy and procedure acts as a safeguard to prevent paying unnecessary services.  
    • In addition, the billing hospital needs to distinguish between the Technical and Professional Component on the invoice.  This will prevent improper payment of both the technical and professional component.  The facility must communicate this expectation to all hospitals.  If the invoice does not depict the Technical and Professional Component, the facility will not pay the bill.   
Consolidated Billing: 5 Major Categories Skilled Nursing Facility
  1. Ambulance Criterion

    1. An ambulance trip that transports a beneficiary to the SNF for the:
      • initial admission, or
      • from the SNF following a final discharge.
    2. Medically necessary ambulance services that are furnished in conjunction the following excluded service categories:
      • Cardiac Catheterization
      • Computerized Axial Tomography (CT) Scans
      • Magnetic Resonance Imaging (MRIs)
      • Ambulatory Surgery that involves the use of an Operating Room
      • Emergency Services
      • Radiation Therapy Services
      • Angiography
      • Certain Lymphatic and Venous Procedures
      • Part B Dialysis Services – Effective April 1, 2000, BBRA unbundled ambulance services that are necessary to transport an SNF resident offsite to receive Part B Dialysis Services

        Medicare does not cover non-ambulance transport.  The SNF is therefore not financially responsible for non-ambulance transport.
      • Ambulance transport is a Medicare covered service and depending on the service and location of the service, the SNF may or may not be fiscally responsible.  It is important to document that the beneficiary is informed of a non-covered service.
      • The Notice of Exclusions from Medicare Benefits Skilled Nursing Facility (NEMB-SNF) form is recommended as a formal means of communicating financial responsibility with the beneficiary.
      • Specific exclusions are identified on the SNF Consolidated Billing Website and updated annually at: 
      • https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html
      • These services are considered outside the PPS bundle, and remain separately billable to Medicare Part B when furnished to an SNF resident by an outside supplier. 
  1. Chemotherapy

    • All chemotherapeutic medications administered in the SNF are the fiscal responsibility of the SNF. 
    • The chemotherapy drug administered at the cancer center or other venue is only excluded if it is specifically identified as exclude on the SNF Exclusion List. It is important to search the list using both the generic and brand name. 
  1. General Excluded Services

    Services that are categorically excluded from SNF Consolidated Billing are the following:
    • Physicians’ Services furnished to SNF residents. These services are not subject to Consolidated Billing and, thus, are still billed separately to the Part B Carrier.
    • Section 1888(e)(2)(A)(ii) of the Social Security Act specifies that Physical Therapy, Occupational Therapy, and Speech-Language Pathology services are subject to Consolidated Billing, even when they are furnished by (or under the supervision of) a physician.
    • Physician Assistants working under a physician’s supervision.
    • Nurse Practitioners and clinical nurse specialists working in collaboration with a physician.
    • Certified Nurse-Midwives.
    • Qualified Psychologists.
    • Certified registered Nurse Anesthetists.
    • Services described in Section 1861(s)(2)(F) of the Social Security Act (i.e., Part B coverage of Home Dialysis Supplies and Equipment, self-care home dialysis support services, and institutional dialysis services and supplies).
    • Services described in Section 1861(s)(2)(O) of the Social Security Act (i.e., Part B coverage of Epoetin Alfa (EPO, trade name Epogen) for certain dialysis patients. Note: Darbepoetin Alfa (DPA, trade name Aranesp) is now excluded on the same basis as EPO);
    • Hospice Care related to a resident’s terminal condition.

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have.  You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

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Topics: Consolidated Billing

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