MEDICARE CONSOLIDATED BILLING

1. MEDICARE CONSOLIDATED BILLING Part II Excluded Services and Consolidated Billing for Home Health Developed by Sandy Sage, R.N.

2. 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.

3. EXCLUDED SERVICES • If a service is “excluded” from consolidated billing; then, it is a service that can be billed directly to Medicare. • The SNF is not responsible for payment of excluded services.

4. EXCLUSIONS • Excluded services are considered outside of the “PPS” bundle and they remain separately billable to Part B when furnished to a SNF resident by an outside provider.

5. EXCLUSIONS • Physician’s services: • Professional component can be billed to Part B • Technical component must be billed to the SNF

6. EXCLUSIONS • Physicians Assistants • Nurse Practitioners • Nurse Midwives • CRNAs • Psychologists

7. EXCLUSIONS • Home dialysis supplies and services • Epoetin Alfa (EPO) • Hospice Care • Admission and Discharge ambulance trips

8. EXCLUSIONS • Surgeries provided in the OR can be billed to Medicare by the hospital. • CMS publishes a list of surgical procedure code exceptions that must be billed to the SNF.

9. “Incident To” Services • While CB excludes professional services that the practitioner performs personally, the exclusion does not apply to physician “incident to” services.

10. “Incident To” Services • These services furnished by others to SNF residents must be billed to Medicare by the SNF and not the service provider.

11. “Incident To” Services • Basic Laboratory Services • Basic Radiology Services • IV Fluid Administration

12. EXAMPLE Chest X-ray • The hospital would bill the “technical component” of the x-ray to the SNF. • The radiologist would bill the “professional” component to Medicare Part B

13. Transmittal A-00-01 • Identifies services that although “incident to” physician services are so intensive and/or costly that they are not included in the SNF plan of care. • They are considered excluded services.

14. Transmittal A-00-01 • Cardiac Catheterization • CT Scans • MRIs • Ambulatory Surgery • Emergency Services • Angiography

16. HOME HEALTH • Under the Home Health (HH) PPS the HH is responsible for billing all HH services which includes nursing and therapy, medical supplies except DME, aides and social services.

17. HH PAYMENT • Payment from Medicare is made to the HH. The HH must pay any other providers who they utilize for the services provided to their patients.

18. CWF EDITS • The CWF will reject all therapy claims if the CWF history indicates the beneficiary was receiving HH benefits on the dates of service billed.

20. THERAPY • All PT/OT/ST and Speech Pathology is included in the payment to the HH.

21. CB INSTRUCTIONS • CMS periodically publishes instructions containing lists of non-routine supplies and therapy codes that are included in the HH Consolidated Billing.

22. MODIFIED BARIUM SWALLOW • One code commonly overlooked when considering the HH CB is 92611. This code is billed when a patient has a Modified Barium Swallow.

23. MODIFIED BARIUM SWALLOW (MBS) • There are two codes billed when an MBS is performed, the x-ray CPT code and the 92611 which is the therapy CPT code.

24. MODIFIED BARIUM SWALLOW • If a patient is receiving HH services, the 92611 code must be billed to the HH agency and the x-ray code must be billed to Medicare.

25. MODIFIED BARIUM SWALLOW • Special Note: If the patient is in a SNF Part A stay, BOTH the x-ray and the therapy code would be billed to the SNF.

26. INCLUDED IN HH CB • Part Time or Intermittent skilled nursing care • Part Time or Intermittent HH aide services • OT/PT/ST • Medical Social Services

27. INCLUDED IN HH CB • Routine and Non-Routine Supplies • Medical services provided by an Intern or Resident in training • One Osteoporosis drug • (All other drugs are excluded)

28. DME- Durable Medical Equipment • DME is medical equipment which can withstand repeated use, is appropriate for use in the home and serves a medical purpose. • Only licensed DME providers may supply this equipment to Medicare beneficiaries. • Examples: Wheelchairs, Walkers, etc.

29. REVIEW • Excluded services for SNF CB includes high dollar testing, Operating Room services, Dialysis and other identified services. • Excluded means the SNF doesn’t have to bill Medicare.

30. REVIEW • Home Health CB is not as inclusive as SNF CB. • Services such as lab, routine x-rays and medications can be billed by other providers.

31. REVIEW • Therapies are always included in the HH CB. • DME is billed by licensed DME providers.