Part B Insider (Multispecialty) Coding Alert

Published on Sat Jan 14, 2006 PDF

Attach modifier 26 to request reimbursement

Beware: When it comes to skilled nursing facility (SNF) patients, Medicare Part B often will not reimburse you for services in the usual manner. Do you know the common billing hazards that can lead to claim denials? Here's how to steer clear.  

Because Medicare Part A typically covers SNF patients and consolidated billing rules apply, you can only report certain codes to Medicare. Do this: Report codes that indicate the professional component to Medicare and then submit a claim to the SNF for the technical component.

Hazard #1: For many of the medications your urologist administers, such as Lupron and Zoladex, you must submit a claim to and seek payment from the SNF itself.

Hidden trap: "Several of our patients actually come from a SNF, but the problem arises when we find out after the fact that the patient is covered under Medicare Part A," says Jennifer Sikkink, CPC, of Urology Specialists in Sioux City, SD. One of the most important questions you can ask a patient is whether she is a resident of a SNF or whether she is from a SNF bed in a nursing facility.

Example: Your urologist sees a patient with bladder cancer and administers a Bacille Calmette-Guerin (BCG) instillation. You report 51720 (Bladder instillation of anticarcinogenic agent [including detention time]) for the drug instillation and J9031 (BCG live [intravesical], per instillation) for the drug itself to the patient's Part B carrier. If the patient is an SNF resident covered by Part A, the carrier will likely deny part of your claim, and your urologist will be out $113.57. For an SNF patient in this scenario, you should report the instillation to the Part B carrier and the cost of the medication to the SNF.

Hazard #2: Urodynamic studies are another example of a common service that requires you to report the professional and technical components separately for SNF patients.

Example: Your urologist performs a cystometrogram and a leak point pressure test in your office on a SNF patient. You should report 51725-26 (Simple cystometrogram [CMG]; professional component) and 51795-26 (Voiding pressure studies [VP]; bladder voiding pressure, any technique; professional component) to Part B. Modifier 26 indicates that you're requesting reimbursement for the professional component. Submit the technical component directly to the SNF.

Watch for: Don't be surprised if the nursing facility requires a contract due to Part A requirements. To receive payment for the technical aspects of services your urologist performs on SNF patients, you may need to have a set contract with the SNF.