Skilled nursing facility consolidated billing
Under the consolidated billing requirement, the skilled nursing facility (SNF) itself bills Medicare for virtually all of the services the SNF residents receive during the course of a covered Part A stay. Payment for this full range of services is included in the SNF Prospective Payment System (PPS) global per diem rate.
Consolidated billing includes physical, occupational, therapies and speech-language pathology services received for any patient that resides in a SNF. Therefore the SNF must work with suppliers, physicians and other practitioners.
Physician services
There are a limited number of services that are excluded from consolidated billing, including services of a physician (except for physical, occupational therapies and speech-language pathology services), physician assistant, nurse practitioner and clinical nurse specialist when they are not an employee of the SNF and when these clinicians are working in collaboration with a physician or under their direct supervision.
Physicians submit claims to Medicare Part B for services that are excluded from SNF consolidated billing.
Consolidated billing
To determine whether a service/procedure is or is not subject to SNF consolidated billing, review the Part B update files on the CMS SNF Consolidated Billing page. Links to the Part B update files are located on the left navigation.
There are four files in the Part B update for SNF consolidated billing:
- File 1: Part A Stay-Physician services
Codes listed are not subject to SNF consolidated billing and should be submitted to Medicare Part B or Durable Medical Equipment contractor, as appropriate. - File 2: Part A Stay-Professional components of services to be submitted with a 26 modifier
Codes listed are not subject to SNF consolidated billing and should be submitted to Medicare Part B for payment consideration. - File 3: Part A Stay-Ambulance
Codes are subject to SNF consolidated billing and will always be denied by Medicare Part B when submitted with a NN, ND or DN modifier. - File 4: Part B Stay Only - Therapy services
These therapy codes are subject to SNF consolidating billing and will always be denied by Medicare Part B.
These services must be provided and billed under arrangement with the SNF.
Physicians may bill the nursing home directly for those services included in SNF consolidated billing if the physician is in a business relationship with the nursing home. The nursing home, which normally bills Medicare Part A once a month, will bill Part A for that service.
During the patient screening process, ask whether the patient is a resident of a nursing home.
If yes, contact the nursing home and ask if the patient is in a covered Part A stay.
If yes, determine if the nursing home has a contract with an entity to provide the services that fall into the consolidated billing guidelines. If a contract exists, refer the patient back to the nursing home for those services.
If no contract exists, develop a business relationship with the nursing home and bill the nursing home for services you provided that are included in consolidated billing.
It is a best practice for a SNF to enter into an arrangement with any outside provider/supplier from which the SNF's residents received services subject to SNF consolidated billing. The absence of an agreement does not relieve the SNF of its overall responsibility to furnish directly or under arrangement for all services that are subject to the consolidated billing requirement.
Reference