Consolidated Billing

Background

Prior to the Balanced Budget Act of 1997 (BBA), a SNF could elect to furnish services to a resident in a covered Part A stay, either:

• Directly, using its own resources;

• Through the SNF's transfer agreement hospital; or

• Under arrangements with an independent therapist (for physical, occupational, and speech therapy services).

In each of these circumstances, the SNF billed Medicare Part A for the services.

However, the SNF also had the further option of “unbundling” a service altogether; that is, the SNF could permit an outside supplier to furnish the service directly to the resident, and the outside supplier would submit a bill to Medicare Part B, without any involvement of the SNF itself.  This practice created several problems, including the following:

• A potential for duplicate (Parts A/B) billing if both the SNF and outside supplier billed;

• An increased out-of-pocket liability incurred by the beneficiary for the Part B deductible and coinsurance even if only the supplier billed; and

• A dispersal of responsibility for resident care among various outside suppliers adversely affected quality (coordination of care) and program integrity, as documented in reports by both the Office of the Inspector General (OIG) and the Government Accountability Office (GAO) (see OIG report no. OEI-06-92-00863, “Medicare Services Provided to Residents of Skilled Nursing Facilities” (October 1994), available at https://oig.hhs.gov/oei/reports/oei-06-92-00863.pdf, and GAO report no. HEHS-96-18, “Providers Target Medicare Patients in Nursing Facilities” (January 1996), available at http://www.gao.gov/products/HEHS-96-18).

Congress then enacted the Balanced Budget Act of 1997 (BBA), Public Law 105-33, Section 4432(b), and it contains a Consolidated Billing (CB) requirement for SNFs.  Under the CB requirement, an SNF itself must submit all Medicare claims for the services that its residents receive (except for specifically excluded services listed below).

Conceptually, SNF CB resembles the bundling requirement for inpatient hospital services that's been in effect since the early 1980s—assigning to the facility itself the Medicare billing responsibility for virtually the entire package of services that a facility resident receives, except for certain services that are specifically excluded.

CB eliminates the potential for duplicative billings for the same service to the Part A fiscal intermediary by the SNF and the Part B carrier by an outside supplier. It also enhances the SNF's capacity to meet its existing responsibility to oversee and coordinate the total package of care that each of its residents receives.

Effective Dates

CB took effect as each SNF transitioned to the Prospective Payment System (PPS) at the start of the SNF's first cost reporting period that began on or after July 1, 1998.

The original CB legislation in the BBA applied this provision for services furnished to every resident of an SNF, regardless of whether Part A covered the resident's stay.  However, due to systems modification delays that arose in connection with achieving Year 2000 (Y2K) compliance, the Centers for Medicare & Medicaid Services (CMS) initially postponed implementing the Part B aspect of CB, i.e., its application to services furnished during noncovered SNF stays.

This aspect of CB has now essentially been repealed altogether by Section 313 of the Benefits Improvement and Protection Act of 2000 (BIPA, P.L. 106-554, Appendix F).  Thus, with the exception of physical, occupational, and speech-language therapy (which remain subject to CB regardless of whether the resident who receives them is in a covered Part A stay), this provision now applies only to those services that an SNF resident receives during the course of a covered Part A stay.

Excluded Services

There are a number of services that are excluded from SNF CB.  These services are outside the PPS bundle, and they remain separately billable to Part B when furnished to an SNF resident by an outside supplier.  However, bills for these excluded services, when furnished to SNF residents, must contain the SNF's Medicare provider number. Services that are categorically excluded from SNF CB are the following:

• Physicians' services furnished to SNF residents.  These services are not subject to CB and, thus, are still billed separately to the Part B carrier.

  • Many physician services include both a professional and a technical component, and the technical component is subject to CB.  The technical component of physician services must be billed to and reimbursed by the SNF.

  • Section 1888(e)(2)(A)(ii) of the Social Security Act specifies that physical, occupational, and speech‑language therapy services are subject to CB, regardless of whether they are furnished by (or under the supervision of) a physician or other health care professional.

• Physician assistants working under a physician's supervision;

• Nurse practitioners and clinical nurse specialists working in collaboration with a physician;

• Certified nurse-midwives;

• Qualified psychologists;

• Mental health counselors (for services provided on or after January 1, 2024);

• Marriage and family therapists (for services provided on or after January 1, 2024);

• Certified registered nurse anesthetists;

• Services described in Section 1861(s)(2)(F) of the Social Security Act (i.e., Part B coverage of home dialysis supplies and equipment, self-care home dialysis support services, and institutional dialysis services and supplies);

• Services described in Section 1861(s)(2)(O) of the Social Security Act, i.e., Part B coverage of Epoetin Alfa (EPO, trade name Epogen) for certain dialysis patients.  Note: Darbepoetin Alfa (DPA, trade name Aranesp) is now excluded on the same basis as EPO;

• Hospice care related to a resident's terminal condition;

• An ambulance trip that conveys a beneficiary to the SNF for the initial admission, or from the SNF following a final discharge.

Physician “Incident To” Services

While CB excludes the types of services described above and applies to the professional services that the practitioner performs personally, the exclusion does not apply to physician “incident to” services furnished by someone else as an “incident to” the practitioner's professional service.  These “incident to” services furnished by others to SNF residents are subject to CB and, accordingly, must be billed to Medicare by the SNF itself.

In Program Memorandum (PM) Transmittal # A‑98‑37 (November 1998, reissued as PM transmittal # A-00-01, January 2000), CMS identified specific types of outpatient hospital services that are so exceptionally intensive, costly, or emergent that they fall well outside the typical scope of SNF care plans.   CMS has excluded these services from SNF CB as well (along with those medically necessary ambulance services that are furnished in conjunction with them).  These excluded service categories include:

• Cardiac catheterization;

• Computerized axial tomography (CT) scans;

• Magnetic resonance imaging (MRIs);

• Ambulatory surgery that involves the use of an operating room;

• Emergency services;

• Radiation therapy services;

• Angiography; and

• Certain lymphatic and venous procedures.

Effective with services furnished on or after April 1, 2000, the Balanced Budget Refinement Act of 1999 (BBRA, P.L. 106-113, Appendix F) has identified certain additional exclusions from CB.  The additional exclusions enacted in the BBRA apply only to certain specified, individual services within a number of broader service categories that otherwise remain subject to CB.  Within the affected service categories the exclusion applies only to those individual services that are specifically identified by HCPCS code in the legislation itself, while all other services within those categories remain subject to CB.  These service categories include:

• Chemotherapy items and their administration;

• Radioisotope services; and

• Customized prosthetic devices.

In addition, effective April 1, 2000, this section of the BBRA has unbundled those ambulance services that are necessary to transport an SNF resident offsite to receive Part B dialysis services.

Effective January 1, 2004, as provided in the August 4, 2003 final rule (68 Federal Register 46060), two radiopharmaceuticals, Zevalin and Bexxar, were added to the list of chemotherapy drugs that are excluded from CB (and, thus, are separately billable to Part B when furnished to a SNF resident during a covered Part A stay).

Finally, effective with items and services furnished on or after October 1, 2021, as provided in the August 4, 2021 final rule (86 FR 42424), certain blood clotting factors and items and services related to the furnishing of such factors were added to the list of services that are excluded from CB.

Effects of CB

SNFs can no longer “unbundle” services that are subject to CB to an outside supplier that can then submit a separate bill directly to the Part B carrier.  Instead, the SNF itself must furnish the services, either directly, or under an “arrangement” with an outside supplier in which the SNF itself (rather than the supplier) bills Medicare.  The outside supplier must look to the SNF (rather than to Medicare Part B) for payment.

In addition, SNF CB:

• Provides an essential foundation for the SNF PPS, by bundling into a single facility package all of the services that the PPS payment is intended to capture;

• Spares beneficiaries who are in covered Part A stays from incurring out-of-pocket financial liability for Part B deductibles and coinsurance;

• Eliminates potential for duplicative billings for the same service to the Part A fiscal intermediary (FI) by the SNF and to the Part B carrier by an outside supplier; and

• Enhances the SNF's capacity to meet its existing responsibility to oversee and coordinate each resident's overall package of care.

Best Practices Guidelines