Hospitals and SNF Consolidated Billing - October 2012

on Tuesday, 23 October 2012. All News Items | Billing


Medicare recently published MLN Matters MM8037 updating the CPT/HCPCS codes for the Skilled Nursing Facility Consolidated Billing (SNF CB) for 2013 and they also published an announcement about the correction of Part B payment errors associated with CB services. So we thought this was a good time to remind hospitals that they need to be aware of the rules for SNF CB and understand how those rules impact hospital billing and payment.

Under the Balanced Budget Act of 1997, all services provided to a Medicare beneficiary in a SNF certified Part A stay are included in a bundled prospective payment to the SNF (SNF PPS). However, because certain services a SNF patient might require are beyond the scope of the nursing facility, there are some exceptions to this requirement. Information on which services are excluded and/or included in SNF CB is available on the SNF Consolidated Billing website, including a spreadsheet of individual CPT/HCPCS codes. (Note that for most categories, the exclusions are listed, but for surgical procedures and therapy rehabilitation services, inclusions are listed.) There is also a General Explanation of the Major Categories of exclusions/inclusions available.

First, you must understand what it means for a service to be included or excluded from Consolidated Billing. If a service is included in CB, only the SNF may bill Medicare directly for that service provided to a patient in a Part A certified SNF stay. When such services are provided to a SNF patient by another entity (such as a hospital), then that entity must obtain payment for the services from the SNF. If the hospital bills Medicare for an included service, Medicare will deny payment. Examples of services that are included in SNF consolidated billing are:

  • Laboratory and simple diagnostic imaging services (other than those provided in association with an ER visit),
  • Simple surgical procedures (such as debridement services),
  • Blood transfusion services, and
  • Rehabilitation therapy services (Physical Therapy, Occupational Therapy, and Speech Language Pathology Therapy) for patients in both a Part A SNF stay and Part B SNF bed.

If a service is excluded from consolidated billing, the service provider (such as a hospital) may bill Medicare directly for that service. For hospitals, the important exclusions to note include:

  • Emergency room services (When ER services go beyond one date of service, providers need to add an ET modifier to the services provided on a different date of service than the ER level of care.),
  • CT scans and MRIs,
  • Cardiac catheterizations,
  • Angiography,
  • Radiation therapy,
  • Chemotherapy, and
  • All but simple surgical procedures.

The best way to handle SNF CB issues is to have good communication with the nursing homes in your area. Consider the following to proactively deal with SNF CB:

  • Have written agreements/contracts with the nursing homes in your area for services provided under arrangement.
  • Obtain information about the patient’s nursing home status (Part A vs. Part B vs. non-skilled NH resident) prior to the provision of services.
  • Be knowledgeable as to which services are included in or excluded from SNF CB (refer to the CPT/HCPCS file spreadsheet when needed).
  • Communicate with the nursing home personnel to ensure that they understand the SNF CB rules.



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