Payment Strategies
Was Your Work Bundled into the Skilled Nursing Facility Payment? Kathleen D. Schaum, MS
At least once a week, a hospital-based outpatient wound care department (HOPD) and/or a qualified healthcare professional (QHP) calls this author and is upset because he/she was denied Medicare payment for a service/procedure provided to a patient who was in a Part AYcovered skilled nursing facility (SNF) stay. Even though Medicare providers are supposed to understand the Medicare payment rules for each site of care where they provide services, the HOPDs and QHPs always seem surprised to learn about the ‘‘consolidated billing’’ (CB) component of the Skilled Nursing Facility Prospective Payment System (SNF PPS). Let’s review the SNF PPS to help you understand why your work might be bundled into the SNF PPS and what you can do to ensure payment from either Medicare or the SNF.
OVERVIEW OF SNF PPS When patients with Medicare Part A Fee-for-Service coverage are in an SNF, the facility is paid a comprehensive per diem that represents Medicare’s payment for all costs of furnishing covered Part A services (routine, ancillary, and capital-related costs). The only costs that are not included in the SNF PPS payment are costs associated with operating approved educational activities and costs of SNF consolidated billingV excluded services.
CONSOLIDATED BILLING Similar to the concept of acute care hospital bundling, the CB provision requires the SNF to include on its Part A bill all Medicare-covered services that a resident has received during the course of a covered Part A stay. Under Medicare Part B, only a small list of excluded services can be billed separately by an outside entity. The following is a list of services that are categorically excluded from SNF CB: physician services, including the professional component of diagnostic tests (representing the physician’s interpretation of the test) services of physician assistants, nurse practitioners (NPs), and clinical nurse specialists working in collaboration with a physician services of certified nurse-midwives services of qualified psychologists
services of certified registered nurse anesthetists Part B coverage of home dialysis supplies and equipment,
self-care home dialysis support services, and institutional dialysis services and supplies Part B coverage of epoetin alfa and darbepoetin alfa for certain dialysis patients services furnished by a rural health clinic or federally qualified health center that would otherwise fall within one of the exclusion categories listed above 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 the following categories of exceptionally intensive outpatient hospital services (along with the transportation from the SNF to the hospital and back when the resident’s medical condition requires the use of an ambulance), which are so far beyond the typical scope of SNF care plans as to require the intensity of the hospital setting to be furnished safely and effectively. This exclusion does not apply if these services are furnished in a freestanding [nonhospital] setting: ) cardiac catheterization ) computerized axial tomography scans ) magnetic resonance imaging services ) ambulatory surgery that involves the use of an operating room or comparable setting ) emergency services ) radiation therapy services ) angiography ) certain lymphatic and venous procedure certain specified ‘‘high-cost, low-probability’’ items within the following categories of services, identified by Healthcare Common Procedure Coding System code: ) chemotherapy items and their administration ) radioisotope services ) customized prosthetic devices ambulance services that are necessary to transport an SNF resident offsite to receive Part B dialysis services 2 radiopharmaceuticals, Zevalin and Bexxar Consolidated billing also places, with the SNF itself, the Medicare billing responsibility for all of its residents’ physical
Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc, Lake Worth, Florida. Ms Schaum can be reached for questions and consultations by calling 561-964-2470 or through her e-mail address: [email protected]. Submit your questions for Payment Strategies by mail to: Kathleen D. Schaum, MS, 6491 Rock Creek Dr, Lake Worth, FL 33467. Information regarding payment is provided as a courtesy to our readers, but does not guarantee that payment will be received. Providers are responsible for case-by-case documentation and justification of medical necessity. ADVANCES IN SKIN & WOUND CARE & VOL. 27 NO. 7
298
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Payment Strategies
therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services, regardless of whether the resident who receives the services is in a covered Part A stay. The Centers for Medicare & Medicaid Services (CMS) provides a few files and a manual that help other institutions and QHPs determine if their services are included in the SNF CB. This author used those files and manual to answer some questions commonly asked by HOPDs and QHPs: Q: If an SNF resident, who is in a Medicare Part A stay, goes to a private physical therapist’s office for selective debridement (97597), who should pay the physical therapist? A: The CMS indicates that all PT services are included in SNF PPS and CB for residents in a Part A stay. The physical therapist should look to the SNF for payment. Q: If an SNF resident is not covered by a Medicare Part A stay and goes to a private physical therapist’s office for selective debridement (97597), who should pay the physical therapist? A: The CMS indicates that PT, OT, and SLP are the only services subject to SNF CB for Medicare beneficiaries in an SNF Part B stay. The physical therapist should look to the SNF for payment. Q: If an NP performs surgical debridement and debrides subcutaneous tissue (11042) on an SNF resident who is in a Medicare Part A stay, who should pay the NP? A: The CMS indicates that all 3 surgical debridements (11042, 11043, and 11044) are excluded from CB. The NP should look to Medicare for payment. Q: If a DPM applies a total contact cast (29445), an Unna boot, (29580), or a multilayer compression bandage system (29581) to an SNF resident who is in a Medicare Part A stay, who should pay the DPM? A: The CMS indicates that all 3 compression procedures are excluded from CB when performed by a QHP. The DPM should look to Medicare for payment. Q: If an MD selectively debrides epidermis and dermis (97597) from the wound of an SNF resident who is in a Medicare Part A stay, who should pay the MD? A: The CMS indicates that all active wound management procedures (97597, 97598, 97605, and 97606) are included in CB. The MD should look to the SNF for payment. Q: If an MD provides hyperbaric oxygen therapy (99183) oversight in an HOPD for an SNF resident who is in a Medicare Part A stay, who should pay the MD? A: The CMS indicates that 99183 is excluded from CB. The MD should look to Medicare for payment. Q: If a DO, in his office, provides a thorough history and physical and wound assessment for an SNF resident who is in a Medicare Part A stay, who should pay the DO?
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A: The CMS indicates that 99201Y99215 are excluded from CB. The DO should look to Medicare for payment. Q: If an SNF patient who is in a Medicare Part A stay is sent to the HOPD where a surgical debridement of subcutaneous tissue and muscle is performed, who should pay the HOPD? A: The CMS indicates that all 3 surgical debridement codes (11042, 11043, and 11044) are excluded from CB. The HOPD should look to Medicare for payment. Q: If an SNF patient who is in a Medicare Part A stay is sent to the HOPD where a cellular and/or tissue-based product for wounds (CTP) (old term ‘‘skin substitute’’) is applied, who should pay the HOPD for the procedure? A: The CMS indicates that all of the codes for the application of CTPs (15271Y15278, C5271YC5278) are excluded from CB. The HOPD should look to Medicare for payment for the procedure. Q: If a wound care nurse in an HOPD applies a total contact cast (29445), an Unna Boot (29580), or a multilayer compression bandage system (29581) for an SNF resident who is in a Medicare Part A stay, who should pay the HOPD? A: The CMS indicates that all 3 of the compression codes are included in CB when performed by a wound care nurse in an HOPD. The HOPD should look to the SNF for payment. Q: If an SNF resident who is in a Medicare Part A stay is sent to the HOPD for the application of a negative-pressure wound therapy pump/dressing, who should pay the HOPD for the procedure? A: The CMS indicates that 97605 and 97606 are included in CB. The HOPD should look to the SNF for payment. Q: If an MD working in an HOPD performs selective debridement and debrides epidermis and dermis from the wound of an SNF resident in a Medicare Part A stay, who should pay the HOPD? A: The CMS indicates that 97597 and 97598 are included in CB. The HOPD should look to the SNF for payment. Q: In an HOPD, if a physician sees an SNF resident who is in a Medicare Part A stay and performs a full assessment and management of a chronic wound, who should pay the HOPD? A: The files and Chapter 6 of the Internet-Only Manual section 20.1.1.2 indicate that G0463 is excluded from CB, if the work is performed by a physician. The HOPD should look to Medicare for payment.
&
RESOURCES If you wish to view the SNF CB file that apply to physicians, you can search http://wwwcms.gov/ Medicare/Billing/SNFConsolidatedBilling/2014-Part-B-MAC-Update.html. If you wish to view the SNF CB files that apply to HOPDs, you can search http://wwwcms.gov/ Medicare/Billing/SNFConsolidatedBilling/2014-Part-A-MAC-Update.html. If you wish to view Chapter 6 of the Internet-Only Manual, you can search https://wwwcms.gov/ Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c06.pdf.
299
ADVANCES IN SKIN & WOUND CARE & JULY 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Was Your Work Bundled into the Skilled Nursing Facility Payment? Kathleen D. Schaum, MS
At least once a week, a hospital-based outpatient wound care department (HOPD) and/or a qualified healthcare professional (QHP) calls this author and is upset because he/she was denied Medicare payment for a service/procedure provided to a patient who was in a Part AYcovered skilled nursing facility (SNF) stay. Even though Medicare providers are supposed to understand the Medicare payment rules for each site of care where they provide services, the HOPDs and QHPs always seem surprised to learn about the ‘‘consolidated billing’’ (CB) component of the Skilled Nursing Facility Prospective Payment System (SNF PPS). Let’s review the SNF PPS to help you understand why your work might be bundled into the SNF PPS and what you can do to ensure payment from either Medicare or the SNF.
OVERVIEW OF SNF PPS When patients with Medicare Part A Fee-for-Service coverage are in an SNF, the facility is paid a comprehensive per diem that represents Medicare’s payment for all costs of furnishing covered Part A services (routine, ancillary, and capital-related costs). The only costs that are not included in the SNF PPS payment are costs associated with operating approved educational activities and costs of SNF consolidated billingV excluded services.
CONSOLIDATED BILLING Similar to the concept of acute care hospital bundling, the CB provision requires the SNF to include on its Part A bill all Medicare-covered services that a resident has received during the course of a covered Part A stay. Under Medicare Part B, only a small list of excluded services can be billed separately by an outside entity. The following is a list of services that are categorically excluded from SNF CB: physician services, including the professional component of diagnostic tests (representing the physician’s interpretation of the test) services of physician assistants, nurse practitioners (NPs), and clinical nurse specialists working in collaboration with a physician services of certified nurse-midwives services of qualified psychologists
services of certified registered nurse anesthetists Part B coverage of home dialysis supplies and equipment,
self-care home dialysis support services, and institutional dialysis services and supplies Part B coverage of epoetin alfa and darbepoetin alfa for certain dialysis patients services furnished by a rural health clinic or federally qualified health center that would otherwise fall within one of the exclusion categories listed above 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 the following categories of exceptionally intensive outpatient hospital services (along with the transportation from the SNF to the hospital and back when the resident’s medical condition requires the use of an ambulance), which are so far beyond the typical scope of SNF care plans as to require the intensity of the hospital setting to be furnished safely and effectively. This exclusion does not apply if these services are furnished in a freestanding [nonhospital] setting: ) cardiac catheterization ) computerized axial tomography scans ) magnetic resonance imaging services ) ambulatory surgery that involves the use of an operating room or comparable setting ) emergency services ) radiation therapy services ) angiography ) certain lymphatic and venous procedure certain specified ‘‘high-cost, low-probability’’ items within the following categories of services, identified by Healthcare Common Procedure Coding System code: ) chemotherapy items and their administration ) radioisotope services ) customized prosthetic devices ambulance services that are necessary to transport an SNF resident offsite to receive Part B dialysis services 2 radiopharmaceuticals, Zevalin and Bexxar Consolidated billing also places, with the SNF itself, the Medicare billing responsibility for all of its residents’ physical
Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc, Lake Worth, Florida. Ms Schaum can be reached for questions and consultations by calling 561-964-2470 or through her e-mail address: [email protected]. Submit your questions for Payment Strategies by mail to: Kathleen D. Schaum, MS, 6491 Rock Creek Dr, Lake Worth, FL 33467. Information regarding payment is provided as a courtesy to our readers, but does not guarantee that payment will be received. Providers are responsible for case-by-case documentation and justification of medical necessity. ADVANCES IN SKIN & WOUND CARE & VOL. 27 NO. 7
298
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Payment Strategies
therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services, regardless of whether the resident who receives the services is in a covered Part A stay. The Centers for Medicare & Medicaid Services (CMS) provides a few files and a manual that help other institutions and QHPs determine if their services are included in the SNF CB. This author used those files and manual to answer some questions commonly asked by HOPDs and QHPs: Q: If an SNF resident, who is in a Medicare Part A stay, goes to a private physical therapist’s office for selective debridement (97597), who should pay the physical therapist? A: The CMS indicates that all PT services are included in SNF PPS and CB for residents in a Part A stay. The physical therapist should look to the SNF for payment. Q: If an SNF resident is not covered by a Medicare Part A stay and goes to a private physical therapist’s office for selective debridement (97597), who should pay the physical therapist? A: The CMS indicates that PT, OT, and SLP are the only services subject to SNF CB for Medicare beneficiaries in an SNF Part B stay. The physical therapist should look to the SNF for payment. Q: If an NP performs surgical debridement and debrides subcutaneous tissue (11042) on an SNF resident who is in a Medicare Part A stay, who should pay the NP? A: The CMS indicates that all 3 surgical debridements (11042, 11043, and 11044) are excluded from CB. The NP should look to Medicare for payment. Q: If a DPM applies a total contact cast (29445), an Unna boot, (29580), or a multilayer compression bandage system (29581) to an SNF resident who is in a Medicare Part A stay, who should pay the DPM? A: The CMS indicates that all 3 compression procedures are excluded from CB when performed by a QHP. The DPM should look to Medicare for payment. Q: If an MD selectively debrides epidermis and dermis (97597) from the wound of an SNF resident who is in a Medicare Part A stay, who should pay the MD? A: The CMS indicates that all active wound management procedures (97597, 97598, 97605, and 97606) are included in CB. The MD should look to the SNF for payment. Q: If an MD provides hyperbaric oxygen therapy (99183) oversight in an HOPD for an SNF resident who is in a Medicare Part A stay, who should pay the MD? A: The CMS indicates that 99183 is excluded from CB. The MD should look to Medicare for payment. Q: If a DO, in his office, provides a thorough history and physical and wound assessment for an SNF resident who is in a Medicare Part A stay, who should pay the DO?
WWW.WOUNDCAREJOURNAL.COM
A: The CMS indicates that 99201Y99215 are excluded from CB. The DO should look to Medicare for payment. Q: If an SNF patient who is in a Medicare Part A stay is sent to the HOPD where a surgical debridement of subcutaneous tissue and muscle is performed, who should pay the HOPD? A: The CMS indicates that all 3 surgical debridement codes (11042, 11043, and 11044) are excluded from CB. The HOPD should look to Medicare for payment. Q: If an SNF patient who is in a Medicare Part A stay is sent to the HOPD where a cellular and/or tissue-based product for wounds (CTP) (old term ‘‘skin substitute’’) is applied, who should pay the HOPD for the procedure? A: The CMS indicates that all of the codes for the application of CTPs (15271Y15278, C5271YC5278) are excluded from CB. The HOPD should look to Medicare for payment for the procedure. Q: If a wound care nurse in an HOPD applies a total contact cast (29445), an Unna Boot (29580), or a multilayer compression bandage system (29581) for an SNF resident who is in a Medicare Part A stay, who should pay the HOPD? A: The CMS indicates that all 3 of the compression codes are included in CB when performed by a wound care nurse in an HOPD. The HOPD should look to the SNF for payment. Q: If an SNF resident who is in a Medicare Part A stay is sent to the HOPD for the application of a negative-pressure wound therapy pump/dressing, who should pay the HOPD for the procedure? A: The CMS indicates that 97605 and 97606 are included in CB. The HOPD should look to the SNF for payment. Q: If an MD working in an HOPD performs selective debridement and debrides epidermis and dermis from the wound of an SNF resident in a Medicare Part A stay, who should pay the HOPD? A: The CMS indicates that 97597 and 97598 are included in CB. The HOPD should look to the SNF for payment. Q: In an HOPD, if a physician sees an SNF resident who is in a Medicare Part A stay and performs a full assessment and management of a chronic wound, who should pay the HOPD? A: The files and Chapter 6 of the Internet-Only Manual section 20.1.1.2 indicate that G0463 is excluded from CB, if the work is performed by a physician. The HOPD should look to Medicare for payment.
&
RESOURCES If you wish to view the SNF CB file that apply to physicians, you can search http://wwwcms.gov/ Medicare/Billing/SNFConsolidatedBilling/2014-Part-B-MAC-Update.html. If you wish to view the SNF CB files that apply to HOPDs, you can search http://wwwcms.gov/ Medicare/Billing/SNFConsolidatedBilling/2014-Part-A-MAC-Update.html. If you wish to view Chapter 6 of the Internet-Only Manual, you can search https://wwwcms.gov/ Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c06.pdf.
299
ADVANCES IN SKIN & WOUND CARE & JULY 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
