Wiki Home Health Consolidated Billing

[bethb]

We bill Medicare Part B / professional services. Our physician is a dermatologist. We billed Medicare Part B for a laboratory service, 88305, global billing, as our physician performs and interprets the test in his office and has the appropriate CLIA certification.

Medicare Part B denied payment for 88305 stating it is a non-covered charge; Home Health Consolidated billing and payment applies. We are familiar with SNF consolidated billing, and know that the technical component of the test would not be paid under Part B if the patient was under a covered Medicare Part A stay in a Skilled Nursing Home. BUT, I cannot find any rules governing consolidated billing regarding beneficiaries receiving covered Home Health services, other than consolidation applies to the following:

Skilled Nursing care
Home Health aide services
PT, OT, SLP
Medical Social Services
Routine and nonroutine medical supplies
Medical services provided by an intern or resident-in-training..
Care for home bound patients..

None of those apply to our situation. Am I missing something regarding physician services / professional services / Part B billing and Home Health Consolidated Billing? Is there anyone who can shed some light on this? Anyone else come across the same denial for their Part B billing?

Thank you all.

Beth

 

[KLRuhe]

Yes, we have the same problem. I don't have any answers though. I was going to post the same question today when I ran across your post.

Our Medicare carrier is telling us we have to send a redetermination, but it's hard to do that when we don't understand the denial! Our carrier is Noridian. Who is yours?

Kay, CPC

 

[bethb]

Hi. Thank you for replying! Our carrier is Novitas. (Pennsylvania) There is plenty of information regarding the consolidated billing rules, etc, for beneficiaries under a Part A covered stay in a skilled nursing facility, but I cannot find anything regarding Home Health consolidated billing. I have even tried finding a contact at CMS for help but I cannot find that either. I feel as though CMS is almost "hiding" these rules because they are not clearly obtainable as the Skilled Nursing Facility CB rules are. Are the technical and professional components unbundled when the patient is under a home health plan of care? That is a simple question yet I cannot find an answer. And our carrier will NOT help us, they just tell us to appeal if we disagree. Medicare stresses correct billing and such but how are we supposed to "correctly" bill if the rules cannot be found?

I wanted to be able to take tangible documentation of the rules to our provider so he understands. I am not sure if an appeal would do any good for our situation because I am not quite sure what I am appealing, because I cannot find the rules and regulations.

I guess I'll keep searching. It is good to know that I am not the only one who is having trouble with this.

Thanks again for your post,
Beth

 

[niabe78]

I work for a derm as well and we had a big headache w/this. There is no use in appealing. If the pt had other out/pt services on the same day they will not pay for global path. Once the claim comes back with that denial you can just submit a corrected claim adding modifier 26 for professional component and they will pay.