Consolidated Nursing Home Billing

The 1997 Balanced Budget Act required Medicare to pay for services provided to patients in a Medicare covered Skilled Nursing Facility with a single payment for most services, rather than individually.  The nursing home must bill Medicare for this payment, and may not bill separately for certain services, such as PT/OT, the technical component of x-rays and many drugs.  

Medicare allowed certain services provided by a physician to be billed and paid separately from the consolidated payment.  This includes the professional fee, that is, the nursing home visits in the series 99304--99318. These services are not part of the consolidated payment to the nursing home and are paid to the physician who sees the patient.

Physician practices may not bill for some services when provided to a nursing home patient.  These include, from the CMS website:

For Medicare beneficiaries in a covered Part A stay, these separately payable services include:

• physician's professional services;
• certain dialysis-related services, including covered ambulance transportation to obtain the dialysis services;
• certain ambulance services, including ambulance services that transport the beneficiary to the SNF initially, ambulance services that transport the beneficiary from the SNF at the end of the stay (other than in situations involving transfer to another SNF), and roundtrip ambulance services furnished during the stay that transport the beneficiary offsite temporarily in order to receive dialysis, or to receive certain types of intensive or emergency outpatient hospital services;
• erythropoietin for certain dialysis patients;
• certain chemotherapy drugs;
• certain chemotherapy administration services;
• radioisotope services; and
• customized prosthetic devices.

Notice that is says "Certain chemotherappy drugs."  That means, certain other chemotherapy drugs are included in the consolidated payment, when provided to a patient in a Medicare covered SNF, whether the patient receives the medication at the SNF or in the physician office.  The physician may not know that the patient is in a Medicare covered SNF at the time the patient presents to the office.  In that case, the drugs should be provided/paid for by the nursing home, as part of their consolidated payment.  If the physician offices finds this out prior to administering the drug, that works best, of course.   CMS publishes a list of drugs that are included in the payment.

If the only service that the physician in your practice provides is visits to patients in nursing home, this does not effect you.

If you have patients who are in nursing homes come to your office, and you provide the technical component of an x-ray, PT, or chemotherapy, this is an issue for you.  You must identify these patients prior to providing the service, and work with the nursing home to provide the patient with the service, or pay your office if it is a service that can only be done by you in your office.

There are three MedLearn Matters Articles on this topic in resources.  One has links to more information on the CMS website.