Q&A: Consolidated billing under PDPM

Nov 07, 2019
Billing Alert for Long-Term Care

Editor’s note: The following information was covered during HCPro’s live webinar, “SNF Consolidated Billing Under PDPM,” with Jennifer Matoushek, MBA/HCM, CPC. View it now on demand.

Under PDPM, if there is a less than three-day interruption with a hospital, are any of the services during that interruption included in consolidated billing (CB)?

Something very important to note with CB is that if your resident was not in the facility at midnight, the nursing facility would not bill for services provided on that day under CB. You want to be sure that when SNFs are reviewing their census report, they’re accurate and that residents were truly in the bed at midnight. If not, the billing office should be notified to properly bill.

Is chemotherapy always excluded from SNF CB?

No, not always. Only the specific chemotherapy agents listed in the Help file are excluded. The SNF is responsible for the payment to the other provider for non-excluded chemotherapy drugs. That’s why I stress for facilities to access that Help file (2019 Part A MAC Update) to guide them through what codes are included or excluded in CB (https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2019-Part-A-MAC-Update.html).

When you have a Medicare Part A-stay resident receiving dialysis treatment, is the SNF responsible for the ambulance transportation?

No, the SNF is not responsible as long as the dialysis is being done at what is categorized as an end-stage renal disease facility.

Do the CB rules apply to Medicare replacements?

So as far as Medicare replacements are concerned, such as Medicare Advantage or Medicare HMOs, they all have their own rules. Many times they do follow the Medicare fee-for-service rule for CB. However, providers need to make sure they’re asking each of their plans to follow what CB rules they have in place. With the change of PDPM, a lot of other commercial insurances are changing their requirements, especially for billing under PDPM. Providers should work with these and Medicare replacements to make sure they’re billing properly.

I do encourage staff members to be well aware of Medicare Advantage and other replacements, to have a great understanding of the information they need in order to bill properly.

What are the main points facilities need to keep in mind to make sure they’re billing accurately under PDPM?

The biggest takeaway: Ensure that you have your admissions process down. Understand what questions need to be asked ahead of time before admitting a resident. Ensure you’re not admitting a resident and having to pay for a certain procedure or drug that the SNF may not be reimbursed for. Educate staff on that admissions process and firm up the front end to ensure the back-end billing process is accurate and the SNF is getting reimbursed for those services.




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