medicare consolidated billing part i consolidated billing developed by sandy sage r n n.
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MEDICARE CONSOLIDATED BILLING Part I Consolidated Billing Developed by Sandy Sage R.N . Learning Outcomes. Explain when and why consolidated billing was implemented. Discuss what is included and excluded from SNF and HHA consolidated billing payments.

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medicare consolidated billing part i consolidated billing developed by sandy sage r n

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

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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.
overview
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.
skilled nursing facility
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.

snf background
SNF BACKGROUND
  • Directly, using its own resources
  • Through a SNF’s transfer agreement with hospital
  • Under arrangements with an independent therapist
snf background1
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
snf background2
SNF BACKGROUND

Unbundling created several problems including:

  • Potential duplicate billing
  • Increased out of pocket liability for the beneficiary
  • Decreased quality of care
duplicate billing
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.
increased liability
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.
decreased quality
Decreased Quality
  • Multiple outside entities furnishing and billing services diminished the SNF’s capacity to oversee and coordinate the care received by its residents.
balanced budget act 1997
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
benefits of cb
BENEFITS of CB
  • Eliminates potential for duplicate billing
  • Enhances the SNF’s capacity to oversee and coordinate the care of its residents
consolidated billing
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.
pt ot st
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.
pt ot st1
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.
pt ot st2
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.
emergency services
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.
emergency services1
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.
emergency services2
EMERGENCY SERVICES
  • When services related to the ER encounter span more than one date, Medicare will reject the claim as a SNF overlap.
emergency services3
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.
emergency services4
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.
emergency services5
EMERGENCY SERVICES
  • Information about the ET modifier is detailed in the 03/03/2006 Transmittal #881 or CR5389.
snf part a stay
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.
snf responsibility
SNF Responsibility
  • SNF bills Medicare for payment of Part A covered services
  • Outside providers will look to the SNF for payment
review
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.
review1
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.
review2
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.
review3
REVIEW
  • Emergency services spanning more than one day can be billed with the ET modifier.
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Contact:

Sandy Sage R.N.

ssage@dodgecountyhospital.com