MDS Alert

Published on Wed Nov 23, 2005 PDF

Put the plug in this potential payment drain.

What little the PPS giveth for some RUGs, consolidated billing can quickly take away--especially if you don't take a proactive approach to managing high-priced services that aren't carved out of the Medicare per diem.

Implementing the following steps will prevent your SNF from being blindsided by huge bills for non-excluded services--and also put you in the driver's seat for arranging and overseeing each resident's total package of services.

1. Case manage physician visits. When you send a resident out for a physician visit or procedure, case manage the process and follow through to see what services the resident received, advises Yelena Koltsova, MS, a consultant with Wern & Associates in Warren, OH.

Example: "If the person is in the facility for a hip fracture and he needs to go to the orthopedist for follow-up, call the doctor to schedule the appointment and ask what the surgeon will need, such as imaging studies or lab work," Koltsova advises.
Then tell the physician to order those services, and the facility will have the results sent to the office along with the resident or ahead of time. "Otherwise, the surgeon or other specialist may order expensive imaging, such as CAT scans or MRIs, to be performed on-site, where the facility ends up with the bill." (Big-ticket items, such as CAT scans, MRIs and radiation therapies, are excluded only when provided by a bona fide hospital outpatient department that bills under the hospital's provider number.)

Tip: If the physician insists that his office do the labs or x-rays, make arrangements with the office to receive the bill and pay them the customary rate, advises Marilyn Mines, RN, BC, director of clinical services, with FR&R Healthcare Consulting in Deerfield, IL.

2. Check the HCPCS codes for a service or item before a resident receives it. Check the HCPCS code of a service that a physician orders to see if the service or item is excluded from CB, says Claudia Reingruber, CPA, principal of Reingruber & Company in St. Petersburg, FL.

For example, chemotherapy and its administration, as well as radioisotopes and their administration, are identified in the statute by HCPCS code, according to a MedLearn Matters article (SE0432). "These services are separately billable in all care settings, but the exclusion applies only to the codes specified in the Social Security Act and subsequent regulations," the article points out.

Watch out: If the chemotherapy service is rendered at a non-Medicare certified site, the facility would be responsible even if the HCPCS indicated that it would be an exclusion, says Mines.

Also, keep in mind that even if a chemotherapy agent is excluded, the facility would still be responsible for paying for IVs, IV tubing and other medications provided during the chemotherapy session.

Heads up: Look up HCPCS codes at www.cms.hhs.gov/providers/snfpps/snffi.

3. As part of case management, discuss equivalent chemotherapy agents with the resident's oncologist or attending physician. Exorbitantly expensive chemotherapy costing thousands of dollars a treatment can jeopardize your facility's bottom line. So if the HCPCS code for a particular chemotherapy agent isn't excluded, discuss the situation with the oncologist up front.

"It's always appropriate for the facility medical director and other team members (nurses, consulting pharmacists, etc.) to discuss reasonable and equivalent alternatives with a resident's prescribing physician," says nurse attorney Janet Feldkamp with Benesch Friedlander Coplan & Aronoff LLP in Cleveland.

"An example might include [asking about] equivalent chemotherapy drugs to one that isn't excluded from the PPS rate ... if the resident's treatment would not be compromised," Feldkamp says.

4. Enlist residents' and families' cooperation with consolidated billing. "Counsel residents/families about consolidated billing during the admission process," advises Jan Zacny, RN, with BKD Southern Missouri in Springfield, MO.

Also give residents/families a reminder about consolidated billing when they leave the facility on an outing or therapeutic leave of absence. Instruct the resident/family or responsible person to contact the facility if the resident requires medical attention unless it's an emergency, says Mines.

Remember: You can capture physician visits at P7 during the MDS lookback for a resident on a temporary leave of absence, according to the RAI user's manual.

5. Include services on the UB-92 that aren't excluded from consolidated billing. The SNF doesn't bill anything on the UB-92 that it's not responsible for paying under the PPS rate, says Reingruber.

But if the resident received cancer chemotherapy that wasn't excluded from consolidated billing, the SNF should include that on the UB-92, says Sondra Enger, a reimbursement specialist with FR&R Healthcare Consulting.

"The SNF won't get paid any more than the all-inclusive RUG rate," Enger says. But itemizing the services provided and including the related diagnosis code(s) helps justify the RUG level billed, she adds.