Optometry Coding & Billing Alert

Published on Mon Sep 01, 2008 PDF

Question: We performed fundus photos on a patient in a skilled nursing facility, and Medicare would not pay the full bill, saying that the SNF was responsible for payment. Is there a list somewhere of what codes Medicare will cover while a patient is in an SNF, and what codes the SNF is responsible for?

Iowa Subscriber

Answer: Coding services for SNF patients falls under the complicated rules for consolidated billing. The SNF is responsible for most of the care the patient receives under Part A, and the SNF should reimburse you directly for those procedures.

Find Medicare's consolidated billing overview online at http://www.cms.hhs.gov/SNFConsolidatedBilling.

Exception 1: Medicare excludes physician services from consolidated billing -- instead of billing the SNF, you should bill your Part B carrier for those services. CMS excludes all of the E/M codes (99201-99499) and eye exam codes (92002-92014) as physician services. For the complete list, see "File 1" at the preceding URL.

Exception 2: For diagnostic tests that have both a professional component and a technical component (for example, 92250, Fundus photography with interpretation and report), Medicare wants you to split the bill.

The SNF is responsible for the technical component, while you can report the professional component to your Part B carrier with modifier 26 (Professional component) appended to the CPT code for the service.

To get paid for the technical component, submit a bill to the SNF with modifier TC (Technical component) appended to the code. For a list of these codes, see "File 2" at the preceding URL.