Basics of SNF Consolidated Billing (CB)
In the Balanced Budget Act of 1997, Congress mandated that payment for the majority of services provided to beneficiaries in a Medicare covered SNF stay be included in a bundled prospective payment made through the Part A Medicare Administrative Contractor (MAC) to the SNF. These bundled services had to be billed by the SNF to the Part A MAC in a consolidated bill. No longer would entities that provided these services to beneficiaries in a SNF stay be able to bill separately for those services. Medicare beneficiaries can either be in a Part A covered SNF stay which includes medical services as well as room and board, or they can be in a Part B non-covered SNF stay in which the Part A benefits are exhausted, but certain medical services are still covered though room and board is not.
History of SNF Consolidated Billing
Prior to the Balanced Budget Act of 1997 (BBA), a SNF could elect to furnish services to a resident in a covered Part A stay, either directly, using its own resources; through the SNF’s transfer agreement hospital; or under arrangements with an independent therapist (for physical, occupational, and speech therapy services). However, the SNF also had the further option of “unbundling” a service altogether; that is, the SNF could permit an outside supplier to furnish the service directly to the resident, and the outside supplier would submit a bill to Medicare Part B, without any involvement of the SNF itself. This practice created several problems. Congress then enacted the Balanced Budget Act of 1997 (BBA), Public Law 105-33, Section 4432(b), and it contains a Consolidated Billing (CB) requirement for SNFs. Under the CB requirement, an SNF itself must submit all Medicare claims for the services that its residents receive (except for specifically excluded services).
Excluded Services from CB
There are a number of services that are excluded from SNF CB. These services are outside the PPS bundle, and they remain separately billable to Part B when furnished to an SNF resident by an outside supplier. However, bills for these excluded services, when furnished to SNF residents, must contain the SNF’s Medicare provider number. Services that are categorically excluded from SNF CB are the following:
- Physicians’ services furnished to SNF residents. These services are not subject to CB and, thus, are still billed separately to the Part B carrier.
- Many physician services include both a professional and a technical component, and the technical component is subject to CB. The technical component of physician services must be billed to and reimbursed by the SNF.
- Section 1888(e)(2)(A)(ii) of the Social Security Act specifies that physical, occupational, and speech‑language therapy services are subject to CB, regardless of whether they are furnished by (or under the supervision of) a physician or other health care professional.
- Physician assistants working under a physician’s supervision;
- Nurse practitioners and clinical nurse specialists working in collaboration with a physician;
- Certified nurse-midwives;
- Qualified psychologists;
- Certified registered nurse anesthetists;
- Services described in Section 1861(s)(2)(F) of the Social Security Act (i.e., Part B coverage of home dialysis supplies and equipment, self-care home dialysis support services, and institutional dialysis services and supplies);
- Services described in Section 1861(s)(2)(O) of the Social Security Act, i.e., Part B coverage of Epoetin Alfa (EPO, trade name Epogen) for certain dialysis patients. Note: Darbepoetin Alfa (DPA, trade name Aranesp) is now excluded on the same basis as EPO;
- Hospice care related to a resident’s terminal condition;
- An ambulance trip that conveys a beneficiary to the SNF for the initial admission, or from the SNF following a final discharge.
Physician “Incident To” Services
While CB excludes the types of services described above and applies to the professional services that the practitioner performs personally, the exclusion does not apply to physician “incident to” services furnished by someone else as an “incident to” the practitioner’s professional service. These “incident to” services furnished by others to SNF residents are subject to CB and, accordingly, must be billed to Medicare by the SNF itself.
To summarize
SNFs can no longer “unbundle” services that are subject to CB to an outside supplier that can then submit a separate bill directly to the Part B carrier. Instead, the SNF itself must furnish the services, either directly, or under an “arrangement” with an outside supplier in which the SNF itself (rather than the supplier) bills Medicare. The outside supplier must look to the SNF billing services (rather than to Medicare Part B) for payment.
We hope this article would have cleared all the confusion about SNF consolidated billing (CB). For detailed information about SNF consolidated billing (SNFCB) refer to CMS’s SNF Consolidated Billing page. Medisys Data Solutions is a leading medical billing company providing complete assistance in medical billing and coding. We can assist you in receiving accurate insurance reimbursement from private and government payers for your skilled nursing facility (SNF). To know more about our SNF billing services, contact us at info@medisysdata.com/ 302-261-9187.
