What Services Are Provided In A Skilled Nursing Facility

Mrs B, ane of your patients with metastatic breast cancer, enters your office to receive pamidronate every bit regularly scheduled. She showtime has blood drawn to determine the creatinine level, and the 2-60 minutes infusion is administered. The patient is a Medicare beneficiary, and your role submits for reimbursement through Medicare Part B. Weeks afterward, the office receives a notice from Medicare that all charges on the claim accept been denied. Why? Because Mrs B was a Medicare patient in a covered Medicare Office A stay in a skilled nursing facility (SNF) at the time of her appointment in your part.

Like scenarios play out in oncology practices across the United States every 24-hour interval. How to obtain reimbursement for services provided to a SNF resident is among the most frequently asked coding and billing-related questions. The challenge is related to consolidated billing, a prospective payment arrangement that covers services within the scope of care at an SNF. Oncology practices can submit for reimbursement through Medicare Part B for those services excluded from the consolidated billing package. Thus, an understanding of the inclusions and exclusions of consolidated billing is essential for appropriate reimbursement.

Overview of SNF Consolidated Billing

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Consolidated billing was established by the Centers for Medicare & Medicare Services (CMS) in 1998 to help eliminate indistinguishable billings for services rendered to SNF residents by multiple providers. With consolidated billing, an SNF receives a basic per diem rate per level of care for each resident. The SNF is by and large the only entity that can pecker Medicare for the services provided to patients while they are residents. All the same, CMS excludes some categories of services from consolidated billing considering they are costly or require specialization; these exclusions are specifically identified in legislation. Oncology practices can seek reimbursement for excluded services directly through Medicare Part B but must obtain reimbursement for services included in SNF consolidated billing from the SNF itself.

The list of drugs and services included in consolidated billing is not clear-cut. Chemotherapy is one of the iv major categories of services excluded from SNF consolidated billing, but not all chemotherapy drugs are excluded. For example, fluorouracil, interferon, methotrexate, mesnex, leuprolide, and goserelin are included in SNF consolidated billing. Many nonchemotherapy drugs that are usually given to patients with cancer, such as antiemetics, pain relievers, bisphosphonates, and erythropoietin are also included. The complexity of consolidated billing extends across drugs to a range of services provided in the practice setting. Physicians' professional services (such as all levels of office visits) and near chemotherapy administration services are excluded and thus reimbursable directly through Medicare Part B. On the other hand, assistants of nonchemotherapy drugs, laboratory studies, and near procedures are included in consolidated billing and are reimbursable but through the SNF.

To beak an SNF, the oncology practice must submit a CMS-1500 class complete with correct revenue codes, dates of services, and a CPT or HCPCS code for each item billed to the SNF. The practise should also include a disclaimer stating that the pecker reflects Medicare rates. Many oncology practices report that reimbursements from SNFs are difficult to obtain. Indeed, the toll of oncology services increases the total cost of intendance for an SNF resident beyond the per diem charge per unit the SNF volition receive. But the potential for oncology services should be expected past the SNF, given that the total intendance needs of the patient are known and advisedly evaluated before the patient is admitted. Although the reasons for the challenges in reimbursement from a SNF are unclear, there are steps that oncology practices tin can take to increase the likelihood of authentic billing and timely reimbursement for services provided to Medicare beneficiaries.

Increasing the Likelihood of Appropriate Reimbursement for SNF Residents

Knowing which services are excluded from SNF consolidated billing and which are included is the almost important step in ensuring appropriate billing (Table one). Lisa Gahara, Health Plan Manager and Billing Supervisor, New Hampshire Oncology-Hematology PA (Hooksett, NH), maintains a detailed listing of services with columns for appropriate J codes or CPT codes, the billing unit, and the source of reimbursement (Medicare or SNF). She modifies the list according to information provided on the CMS Web site (www.cms.hhs.gov/SNFConsolidatedBilling/01_Overview.asp) and in periodic issues of MLN Matters, a CMS electronic newsletter that provides updates to excluded services. For example, a May 2008 issue of the newsletter noted that panitumumab injection (lawmaking J9303) was added to the list of drugs excluded from consolidated billing, retroactive to January i, 2008. Gahara's list allows her and other billers and coders in the office to bill accurately for services provided, simply issues can still arise. She says that a long list of outstanding bills to a local SNF prompted the office administrator of the SNF to inquire for a face up-to-confront meeting with the oncology exercise to sort through the charges and discuss the possibility of developing a straight contract between the practice and the SNF.

Tabular array 1. Reimbursement for Drugs and Services Commonly Provided in the Oncology Practise Setting

Identifying patients as SNF residents is an equally important step toward appropriate billing. Ideally, the do should know the patient's status at the fourth dimension the appointment is scheduled. Oncology practice staff should educate their patients and their families nearly the need to inform staff most the patient's condition when making an appointment. Staff should likewise encourage local SNFs to annotation that a patient is a resident when calling for an appointment. Oncology practice staff who brand appointments should enquire if the patient is a resident of a SNF if this data is not provided. The initial conversation between the practise and the SNF provides an opportunity to discuss the potential charges for services that may be included in consolidated billing.

If the patient's condition has non been clarified when the appointment is fabricated, information technology should be documented at the time the patient is seen in the oncology role. If the patient is a SNF resident, Gahara suggests alerting the SNF before rendering services that are included in consolidated billing. "It'south a skilful idea to call the SNF, to verify that the patient is truly considered an SNF resident and to let it know what services the exercise volition be providing," she says. She explains that this call is a courtesy to the SNF in case it wants to purchase the drug and administer information technology at the SNF.

Timeliness of reimbursement from a SNF is often an issue, even when billing is done appropriately. Although the invoice from the oncology exercise is processed at the SNF, the invoice may demand review and approving by staff at a corporate office, which is sometimes in another state. This can filibuster payment by lx days or more. Gahara acknowledges the difficulty in receiving timely reimbursement from a SNF. "You lot accept to stay on top of information technology and have someone from the practise monitor the charges sent to SNFs to make sure you lot receive payment," she says. She adds that if payment is non received within 90 days, she calls the accounts payable function manager at the SNF. "Typically, we are paid within another 30 to 60 days later the telephone call," she said.

Information technology may also exist helpful for an oncology practice to develop a contract or agreement with local SNFs to establish a reimbursement process for services included in consolidated billing. The CMS Spider web site offers a template for an under arrangement agreement, which provides written documentation of an agreement between a SNF and a supplier of services about a process and terms of payment. The template is bachelor at world wide web.cms.hhs.gov/SNFPPS/Downloads/bpsampleagr1.pdf.

Reimbursement Tips from Medicare and Skilled Nursing Facilities (SNFs)

• Maintain an up-to-date list of drugs and services included and excluded in SNF consolidated billing

• Make up one's mind whether a patient is a SNF resident, preferably at the time an appointment is scheduled

• Brainwash patients, their families, and staff at local SNFs about the need to inform the practise almost the patient's status when making an appointment

• Alert the SNF to charges for services included in consolidated billing earlier the services are provided

• Continually monitor the status of invoices sent to SNFs and prompt as necessary

• Plant written payment arrangements with local SNFs

Copyright © 2008 by American Club of Clinical Oncology.

Source: https://ascopubs.org/doi/full/10.1200/jop.0853001

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