SNF Consolidated Billing

What You Need to Know

Congress passed the Balanced Budget Act in 1997, which established consolidated billing for Medicare beneficiaries in a Part A covered stay at a Skilled Nursing Facility. Medicare Part A covers up to 100 days at a SNF and pays a bundled prospective payment for all care the patient receives during their covered stay. Outside providers are not able to bill Medicare separately for their services because it is already included in the payment to the SNF and would therefore be considered unbundling. If the SNF is not able to provide certain services directly, they can make arrangements with an outside provider. In this scenario, the provider would bill the SNF instead of the DME MAC for their services.

Although most medical care is included in the bundled payment to the SNF, there are some services that are specifically excluded from consolidated billing. One of these exclusions is customized prosthetic devices. Most prosthetic HCPCS codes are not included in the Prospective Payment System, and can therefore be billed separately to the DME MACs by an outside provider. Conversely, bracing codes are typically included in the consolidated billing and cannot be billed separately while a patient is in their Part A covered stay.

What this Means for You

To ensure payment for your services, you must understand the rules of SNF consolidated billing. Whether you can bill Medicare directly depends on both the patient's coverage and the specific HCPCS codes you are billing. Before providing prosthetic and/or bracing items to a Medicare patient, you should follow three important steps to determine where to send your claim.

Step 1: When verifying your patient's Medicare eligibility online, it is important to always check if they are currently staying in a SNF. While most patients receive services directly at the facility, some may leave the SNF and attend medical appointments in the office. If you unknowingly provide services to a SNF patient and bill your DME MAC, you risk denial due to consolidatedbilling. And even though you can bill the SNF directly for these services, the facility likely won't pay without a prior agreement.

Step 2: If your patient is staying in SNF, contact the facility to determine if they are currently in a covered or non-covered stay. Patients are typically in a Part A covered stay within their first 100 consecutive days at the SNF. When coverage from Medicare Part A runs out (i.e. after 100 days), or if the patient does not have Part A coverage, then they are in a Part B non-covered stay. You can bill Medicare directly for all bracing and prosthetic devices delivered to a patient in a non-covered stay. 

Step 3: For patients in a Part A covered stay, you need to verify whether the devices you are providing are included or excluded in SNF consolidated billing. In general, most prosthetic HCPCs codes are excluded while most bracing HCPCS codes are not, but there are some exceptions. To be certain, you can use the Consolidated Billing Tool on either the CGS or Noridian website. Any HCPCS codes that are excluded will say "separately payable" during a Part A SNF stay, which means the provider can bill Medicare directly for these services. If the tool states that the code is "not separately payable," then the provider cannot bill Medicare and must make arrangements with the SNF for payment. If the SNF does not want to pay for the services, then you will need to wait until the Part A covered stay is over, at which time you can bill Medicare directly.

For more information, visit the Consolidated Billing article on the CMS website.