MEDICARE CONSOLIDATED BILLING Part I Consolidated Billing Developed by Sandy Sage R.N .

1. MEDICARE CONSOLIDATED BILLINGPart IConsolidated BillingDeveloped by Sandy Sage R.N.

2. Learning Outcomes • Explain when and why consolidated billing was implemented. • Discuss what is included and excluded from SNF and HHA consolidated billing payments. • Recognize admission source codes and discover why they are important. • Restate what hospital registration responsibilities are and why they are important if a patient is in a PPS stay.

3. OVERVIEW • Consolidated Billing essentially places the Medicare billing responsibility, for certain services, with the SNF or Home Health agency if they are receiving payment from Medicare for a beneficiary’s packaged services.

4. Skilled Nursing Facility BACKGROUND Prior to 1997, a SNF could elect to furnish services to a resident in a Part A stay in several different ways.

5. SNF BACKGROUND • Directly, using its own resources • Through a SNF’s transfer agreement with hospital • Under arrangements with an independent therapist

6. SNF BACKGROUND • The SNF could elect to bill Medicare Part A for all services a resident received - or - • The SNF could unbundle the services, allowing outside service providers to bill Medicare Part B

7. SNF BACKGROUND Unbundling created several problems including: • Potential duplicate billing • Increased out of pocket liability for the beneficiary • Decreased quality of care

8. Duplicate Billing • Allowing outside entities to bill Part B directly caused problems when the SNF would also bill Part A for the same services. • Part A and Part B didn’t communicate very well at the time.

9. Increased Liability • Billing for Part B services that could have been billed under Part A increased the beneficiary liability for Part B deductibles and coinsurance.

10. Decreased Quality • Multiple outside entities furnishing and billing services diminished the SNF’s capacity to oversee and coordinate the care received by its residents.

11. Balanced Budget Act 1997 • Enacted by Congress • Requires a SNF to submit all Medicare claims for the services that its resident receives • Some services are excluded

12. BENEFITS of CB • Eliminates potential for duplicate billing • Enhances the SNF’s capacity to oversee and coordinate the care of its residents

13. Consolidated Billing • With the exception of PT, OT and ST, this provision for consolidated billing applies only to those services that a SNF resident receives during the course of a Part A stay.

14. PT, OT, ST • The law specifically provides that PT/OT/ST and Speech Language Pathology furnished to SNF patients are ALWAYS subject to Consolidated Billing.

15. PT, OT, ST • Therapy is included in CB even when a patient receives therapy during a non-covered stay. • If they are in the skilled section of a nursing home with no Part A benefits, the SNF is still responsible for billing Medicare.

16. PT, OT, ST • If the patient is NOT in a skilled bed and has Part B Medicare, then the therapy provider can bill Medicare directly.

17. EMERGENCY SERVICES • Emergency Room services performed in hospitals, including CAH, are excluded from SNF CB if the beneficiary is in a Part A stay. This includes all services provided during that visit.

18. EMERGENCY SERVICES • Hospitals report emergency services using revenue code 45X. • Also reported with those services are the line item dates the service was performed on.

19. EMERGENCY SERVICES • When services related to the ER encounter span more than one date, Medicare will reject the claim as a SNF overlap.

20. EMERGENCY SERVICES • As of 04/02/2007, Medicare will allow those services to be paid to the hospital if line items on the second date are modified with ET.

21. EMERGENCY SERVICES • The ET modifier will alert the CWF that these are services related to the emergency visit and the overlap edit will be bypassed. • This allows all services to be reported on the correct date of service.

22. EMERGENCY SERVICES • Information about the ET modifier is detailed in the 03/03/2006 Transmittal #881 or CR5389.

23. SNF PART A STAY • Includes a semi-private room, skilled nursing and rehabilitative services and other services and supplies after a 3 day hospital stay.

24. SNF Responsibility • SNF bills Medicare for payment of Part A covered services • Outside providers will look to the SNF for payment

25. REVIEW • If a SNF has a beneficiary in a Part A stay and outside services are required, the SNF must bill Medicare for the services and remit payment to the outside providers themselves.

26. REVIEW • Consolidated billing allows the SNF to effectively oversee the care and services provided to residents in a Part A stay. • It also decreases the possibility of double billing of services to Medicare.

27. REVIEW • The SNF will bill Medicare for therapy services any time the beneficiary is in a skilled bed. • The therapy provider can bill Medicare if the patient is NOT in a skilled bed unit.

28. REVIEW • Emergency services spanning more than one day can be billed with the ET modifier.

29. Contact: Sandy Sage R.N. ssage@dodgecountyhospital.com