Skilled nursing facility (SNF) consolidated billing essentially places the Medicare billing responsibility for the entire package of services SNF residents receive during a covered Part A stay on the SNF itself. The Centers for Medicare & Medicaid Services (CMS) does allow for a short list of exclusions that remain separately billable to Part B by the outside entity that furnishes the excluded service. These exclusions are broken down into five major categories, which depend on both the place of service and the Current Procedural Terminology (CPT) and/or Healthcare Common Procedure Coding System (HCPCS) codes billed.
Prior to sending a Part A resident out for services to another provider or supplier, a SNF should first notify the outside provider the patient is currently a resident in a Medicare Part A stay. The CMS website contains sample notification forms.
Sample payment agreements also are available on the CMS website. When a service is deemed to be the SNF’s responsibility, and the SNF receives a bill from the outside provider, the CMS won’t get involved with any resulting payment disputes between the providers. Therefore, SNFs should consider having a payment agreement in place with outside providers prior to any services being rendered to Part A residents.
A SNF also should be in contact with the outside provider prior to services being rendered to determine which CPT and/or HCPCS codes the outside provider will bill for the service(s) or procedure(s) being performed. Once obtained, the SNF can search these codes on the annual SNF consolidated billing HCPCS updates file to determine whether it’s responsible for the service(s) or procedure(s). The SNF also can identify whether it’s restricted by place of service or provider type.
Although some CPT/HCPCS codes may be listed as exclusions from consolidated billing, they’ll be included—meaning the SNF is responsible—if the service is performed at a place of service that’s not covered as an exclusion, as defined in the major category exclusions explanation. For example, services excluded under Major Category I must be performed on an outpatient basis at a hospital. If a service listed as excluded under Major Category I, such as a surgery, is performed at an ambulatory surgical center, the SNF would be responsible for the cost of this service because it wasn’t performed in an outpatient hospital setting. Likewise, radiation therapy performed at a free-standing cancer center would be the SNF’s responsibility, even though it’s listed as an exclusion. This is because consolidated billing rules state this service only is excluded when performed in an outpatient hospital setting.
Professional services such as physician evaluation and management codes are statutory exclusions and can always be billed to Part B by the rendering provider. However, just because professional services are excluded doesn’t mean other tests and procedures performed in conjunction with the physician visit are too. SNFs also should be aware that codes for diagnostic services often have both a professional and technical component, and the SNF only is responsible for the technical component. The modifier “TC” indicates a technical component of a service or procedure, whereas modifier “26” represents the professional component (not subject to consolidated billing).
These are just a few of the common obstacles SNFs encounter with consolidated billing. While it can be confusing, being aware of what is and isn’t subject to consolidated billing rules—as well as having proper notifications and agreements on file—can save your facility time, frustration and unnecessary cost. For best practices and references to help clear the consolidated billing fog, download our consolidated billing tool.
Contact your trusted BKD advisor if you have any questions.