American Urological Association - Consolidated Billing

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Consolidated Billing

Skilled Nursing Facility (SNF) Patients

Know Who They Are and How to Get Paid

"Is this patient a resident of a skilled nursing facility?" is a critical question your appointment person must ask. This simple question could save you hundreds of reimbursement dollars. Without this information, the services you perform might not be reimbursable.

  • Intro

    Skilled Nursing Facilities (SNF) are subject to consolidated billing. This means most services (e.g., room, board, nursing services, etc.) provided to a Medicare or Medicaid patient in a SNF are reimbursed at a flat per-day rate. Some of the services performed by urologists to patients residing in a SNF are included in consolidated billing. Thus, reimbursement for covered services must be paid to the urologist directly by the SNF, and excluded services must be submitted and reimbursed through the Part B Medicare carrier. The urological services subject to and excluded from consolidated billing are explained below.

  • What is Consolidated Billing?

    CMS issued Program Transmittal 1796 (May 16, 2003) updating the Medicare Carriers Manual Part 3 – Claims Process and clarifying that outside providers and suppliers cannot submit a separate claim to Medicare for services rendered during a SNF covered stay except for "physician professional services." The policy states that unless the services and/or supplies are specifically excluded under consolidated billing, the outside provider must obtain payment from the SNF rather than from Medicare.

    There have been many new transmittals from Medicare since 2003. There are new changes to applicable covered HCPCS/CPT codes and CMS has developed a special section on Skilled Nursing Facilities. To view this special section, go to: www.cms.hhs.gov/center/snf.asp. To view transmittals applicable to SNFs, go to the box on the left of the page and click Transmittals.

    In the situation where a urologist performed services on a SNF patient in the office or in the SNF and the service is not excluded from consolidated billing, the urologist must make arrangements for payment from the SNF. The law is silent regarding the specifics of a SNF's payment to the outside supplier and there are no Medicare requirements. According to the Carriers Manual Claims Review and Adjudication Procedures Section 4210.6:

    "The issue of the outside provider or supplier's payment by the SNF is a private, contractual matter that must be resolved through direct negotiations between the parties. However, services under consolidated billing arrangements must be performed by Medicare certified providers that are licensed to provide the service involved. In addition, payment may not be made if the provider or supplier is subject to OIG sanctions that would prohibit Medicare payment for the service if the provider or supplier were billing independently."

    It is important that a legally binding, written contract between the provider and the SNF is negotiated and executed before services to a SNF patient are supplied either in the office or in the SNF. The assistance of an attorney may be required for such a contract.

  • Professional Services

    Professional services provided to SNF patients either in the SNF or the physician's office may be reimbursed by the Part B Medicare carrier. These services include office visits and certain surgical procedures. The list of physician services reimbursable through Medicare Part B can be found on the CMS website. Refer to the Coding Files, File 1 – Part A Stay – Physician Services. Refer to this list before billing services provided to SNF patients.

    Example: A urologist is called by a SNF to evaluate a patient for gross hematuria. Under consolidated billing requirements, the urologist will be reimbursed for the cystoscopy or any other professional service (i.e., office visit) as long as the service appears on the exclusion list of procedures. Depending on the mobility of the patient, this service might be performed in the urologist's office or it might be wise to schedule the patient in an outpatient setting. In either case, bill the Part B Medicare carrier.

  • Drugs and Biologicals

    Also under File 1, there are HCPCS codes for supplies, certain chemotherapy drugs and prosthetics that are excluded from consolidated billing. Physicians can bill Part B or DMERC directly for these. However, the only drug excluded from consolidated billing and reimbursable in the treatment of urological conditions is mitomycin.

    Prostate Cancer Chemotherapy Drugs Not Reimbursable During First 100 Days
    A urologist's biggest problem is reimbursement for luteinizing hormone-releasing hormone (LH/RH) agonists given to SNF patients. The administration and cost of these drugs are not reimbursable directly to the physician. Many urology offices are now receiving demand-for-repayment letters from their Medicare carriers for improper reimbursement under Part B. Unfortunately, there is no other recourse except to repay the money and try to negotiate with the SNF for payment. The problem with this is that the SNF administrator may not have been aware of this policy and this may prove an obstacle in obtaining reimbursement.

    Example: A Medicare patient has been on LH/RH agonist therapy for a number of months (J3315, triptorelin pamoate injection; J9202, goserelin acetate implant; J9212, leuprolide acetate injection; or J9213 leuprolide acetate implant) and is admitted to a SNF after a hospital stay. It is time for his three-month injection. Do not administer the drug from your inventory to the SNF patient or administer the drug in your office. The SNF should make arrangements to obtain the drug and have it administered under physician supervision on the premises of the SNF or have the patient bring the drug to your office. Remember that the administration injection will not be reimbursed. The cost of the drug and the administration is not reimbursable directly to the urologist, only to the SNF. If the administration of the drug is performed by the urologist, make sure a legal agreement has been developed so the urologist may obtain reimbursement from the SNF for the administration.

    After 100 days when Part A coverage has ended, the urologist may then bill the Part B Medicare carrier directly for reimbursement for the chemotherapy injections and the drug. That is why it is so important to know the status of the SNF patient. A one-day mistake could be very costly to the practice.

  • Diagnostic Procedures

    Certain diagnostic procedures can be billed to the Part B Medicare carrier. Refer to the CMS website and refer to the Coding Files, File 2 - Part A Stay – Professional Component of Services to be submitted with a Modifier -26 to make sure billing of these procedures is allowed.

    Example: Urodynamics testing or radiological diagnostic testing performed on SNF patients can be billed to the Medicare Part B carrier, but claims must be submitted with modifier -26, Professional Component. This means that only the professional component of the code will be reimbursed. If you are performing diagnostic testing in the office or if you take your own equipment to the SNF to perform these tests, reimbursement for the technical component will not occur unless a previous contract has been secured for reimbursement of the technical component through the SNF. Do not attempt to bill without modifier -26 as the claim will be rejected. This might be an example where you would schedule the patient to have this type of testing performed in a hospital setting.

  • Therapy – Physical, Occupation and Speech – Biofeedback

    These types of therapies are never billable to Part B and are subject to consolidated billing whether they are a covered or non-covered Part A service. They will never be reimbursed directly to the urologist through Part A or Part B for patients in a SNF. These codes are subject to SNF consolidated billing rules and must be billed through the SNF. Refer to the CMS website, Coding Files, File 4 – Part B Stay – Therapy Services. The SNF will bill the Part A Intermediary for reimbursement and an arrangement must be made with the SNF for direct reimbursement to the urologist.

    Example: Biofeedback (CPT® codes 90901 and 90911) and treatment(s) for incontinence, pulsed magnetic neuromodulation, per day (0029T) are considered therapies and are not reimbursable directly to the urologist when performed on SNF patients. Do not perform these services on SNF patients and expect reimbursement through Part B.

    Many SNF's are not aware of the changes required under consolidated billing and this is a frustrating position for the urologist who is asked to treat SNF patients. It is almost a "provider beware" atmosphere. It is important that your office staff be trained to identify SNF patients to maintain proper reimbursement from either the SNF or Part B.

    Updates for covered CPT® codes will be periodically provided via CMS' Medical Learning Network (MLN) website, in addition to their section on frequently asked SNF questions. Make arrangements for someone on your office staff to check the web site for any revisions. The AUA will update the membership through articles in the Health Policy Brief.

    For more information on services furnished under an arrangement with an outside entity, review MLNMattersArticles [pdf]. This article outlines ways providers can protect themselves from denials.

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