3. CONSOLIDATED BILLING: TRIMMING THE FAT
Consolidated Billing refers to Items and services that are
considered covered under the Part A PPS scope even if the
SNF does not directly provide those services
Items and services that will be SNF responsibility should be
determined prior to admission
Develop policies and procedures for determining SNF
responsibility and paying related invoices
4. CONSOLIDATED BILLING
Major Category Exclusions
Determining the place of service
Category I has to be provided in hospital or CAH
Obtain procedure codes
Categories of exclusions are further broken down into
excluded codes (outpatient surgery listed as inclusions)
Link to major category list and exclusions list by HCPC
http://www.cms.gov/Medicare/Billing/SNFConsolidated
Billing/2013-Annual-Update.htm
5. CONSOLIDATED BILLING
Part B
If patient resides in a Medicare certified bed Part B therapy
must be billed by the SNF
Barium swallow- ST
If patient is in a non-certified section of the Facility or a
true outpatient, therapy can be billed by therapy provider
or SNF
23X bill type for outpatient therapy services
6. CONSOLIDATED BILLING
General Exclusions
Professional services
For diagnostic tests/procedures SNF is responsible only
for the technical component (modifier TC) not the
professional component of the code (modifier 26)
SNF is not responsible for hospital treatment rooms
Emergency services
SNF not responsible for emergency services including
ambulance transportation
7. CONSOLIDATED BILLING
Ambulance Transportation
SNF Responsible
Related to a non excluded routine service
When transferring to another SNF (Transferring SNF
Responsible)
Exclusions from SNF responsibility
Related to an excluded major category and was
medically necessary
Emergency
Dialysis
Upon admission to SNF
8. CONSOLIDATED BILLING
Non ambulance transportation
These forms may include:
Wheelchair vans
Ambulettes
Facility van
SNF may charge patient
Recommend giving patient notice of exclusion from
Medicare benefit
9. CONSOLIDATED BILLING
Provider Responsibilities
Notifying other providers/suppliers of a covered stay
Entering into agreements with outside providers/suppliers
CMS does not determine the rate of payment but if a
SNF has a history of not covering included services CMS
may find them to be out of compliance with the
Medicare program
Link to sample notice and agreement forms:
http://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/SNFPPS/BestPractices.html
10. CONSOLIDATED BILLING
Determining the Medicare allowable
Fee schedules available on CMS website
Physicians fee schedule look up
Lab fee schedule
DME- prosthetic/orthotic & supplies
Drug average price schedule
Reasonable charge for casts/splints
Outpatient hospital
11. CONSOLIDATED BILLING
Medicare non covered services
Depending on SNF arrangement may be billable to patient if
proper notice is provided
http://www.cms.gov/Outreach-and-Education/MedicareLearning-NetworkMLN/MLNProducts/downloads/Items_and_Services_Not_Covere
d_Under_Medicare_BookletICN906765.pdf
Non ambulance transportation
Eye exams-for fitting/prescribing/changing glasses
Dental services related to care/treatment/removal of teeth
Hearing Aids
13. ADMISSIONS/INTAKE: AUGMENTING PATIENT FILES
Payer verification and eligibility
Payer websites/Clearinghouse
Medicare Common Working File (to be terminated in 2014)
Completion of required paperwork/Admissions agreement
Knowledge of payer type and coverage criteria
Well defined admissions procedures/checklist
Who is responsible for entry of information into software
Processes for maintaining financial information
Manual/Electronic/Network storage
14. ADMISSIONS/INTAKE
Medicare A
Qualifying hospital stay(minimum 3 consecutive days)
Impact of RAC audit of hospital stay
Impact of observation days
Accounting for other skilled stays (SNU/Swing bed)
Verifying requirements for skilled care
Daily skilled nursing services
Rehabilitation 5 days per week
15. ADMISSIONS/INTAKE
Medicare B
Therapy cap usage
$1900 therapy cap
Therapy threshold
$3700
Mandatory medical review (Post payment except for
demonstration states effective April 1)
RAC Prepayment demonstration states- Texas
16. ADMISSIONS/INTAKE
Supplemental insurance- Copies of cards are key
Medigap versus other insurance
http://www.cms.gov/Medicare/HealthPlans/http://www.cms.govhttp://www.cms.gov/Medicare/HealthPlans/Medigap/index.html?redirect
17. ADMISSIONS/INTAKE
Managed Care
Importance of recognizing enrollment prior to admission
Maintaining and updating contracts
Pre-Authorization
Frequency of authorization
Timely filing guidelines
Coverage criteria
Level of care as defined in contract
Compliance claim requirement to Medicare
04 Condition code
19. PART A BILLING STRUGGLES
Unscheduled assessments may take over payment window of
a scheduled assessment
Understanding billing rules for combined assessments
Possibility of one assessment being billed with 2 different
HIPPS codes
Understanding when to bill therapy versus non therapy
HIPPS
21. PART A BILLING STRUGGLES
Change of therapy (COT) being retrospective
Potential need to adjust prior month claim
Increased risk of early/late/missed assessments and how to
bill impacted claims
Unscheduled- Early/Late bill default number of days out of
compliance (when missed MDS would have controlled
payment)
Scheduled- Early bill default number of days early/late bill
default up to late ARD
Missed= Provider liability, send covered claim with span
code 77 and dates applicable to liability
22. PART A BILLING STRUGGLES
Understanding how to bill Unscheduled Assessments
End of therapy (EOT)
End of therapy Resumptive (EOT-R)
Start of therapy (SOT)
Short Stay
Change of therapy (COT)
22
23. EOT OMRA - EXAMPLE
30-Day Window
Grace Days
Day
30
Day
31
Day
32
Day
33
Day
34
Day
35
Day
36
Last
Day
Therapy
1
2
3
EOT
DUE
RHB
RHB
RHB
RHB
LB1
Day
37
Day
38
Day
39
Day
40
24. EOT-R OMRA - EXAMPLE
Day
35
Day
36
Day
37
Day
38
Last Day
Therapy
Day
36
1
2
Day
39
3
Day
40
Day
41
Therapy
Resumes
EOT ARD
5 Consecutive Day Count
0
1
2
3
4
5
EOT-R
Date
RVB
RVB
CC1
CC1
CC1
CC1
RVB
RVB
25. SOT OMRA - EXAMPLE
5-Day Window
Regular Days
Day
1
Day
2
Day
3
Day
4
Therapy
Eval
CC1
CC1
CC1
RHB
Grace Days
Day
5
Day
6
Day
7
5-day
ARD
Day
8
Day
9
Day
10
SOT
ARD
Day
11
26. COT OMRA - EXAMPLE
30-Day Window
Grace Days
Day
30
30
Day
ARD
RH
Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day
31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47
1
2
3
4
5
6
7
1
335
2
3
4
5
6
7
310
RM
RH
COT
RUG
COT
Due
1
2
3
27. PART B BILLING STRUGGLES
Capturing modifiers on claim
CCI edits- modifier 59
Therapy cap exception- modifier KX
Missing modifiers on claims= rejected services
Functional reporting (G codes)
Severity modifiers
27
28. TRIPLE CHECK: REDUCING CLAIM ERRORS
Involvement of interdisciplinary team, nursing, therapy and
billing to review claims prior to submission to payers
Triple check is in addition to regular Medicare meetings
throughout the month with the interdisciplinary team
Claims should be prepared and brought to the triple check
meeting for review
Checklist should be used and signed off (especially if
performing any pieces offsite)
28
29. TRIPLE CHECK
Common items to review:
Necessary documentation has been signed/dated by
physician
MDS have been submitted/accepted/and validation report
has been checked for re-calculations
Patient demographic information
Census data
Charges
29
30. TRIPLE CHECK
Common items to review:
HIPPS code/ARD/and payment dates
Qualifying stay for Part A
Diagnosis code- relevance/sequencing/specification
Occurrence codes
Condition codes
Part B modifiers
Part B G codes
30
31. A/R MANAGEMENT: MAINTAINING A SVELTE AGING
Days outstanding vary by payer type
Medicare/private pay/Medicaid
30 days (should be resolved prior to next billing cycle)
Insurance primary
30 days if able to file electronically
60 days if filing paper
Co-Insurance- Must first wait for primary payer to pay
60 days if filing electronic or auto-crossover
Identify crossover status on remittance advice
90 days if filing paper
31
32. A/R MANAGEMENT
Policies and procedures should be developed for follow up and
tracking of unpaid balances
Accounts receivable software
Using collection notes
Setting user tasks/follow up dates
Paper system
Tickler file
Adding appointments to email/calendar
Excel Tracking
Ability to export data from most A/R systems
32
33. A/R MANAGEMENT
Medicare Follow up
EDI acceptance verification
Daily follow up via DDE
Used to make corrections/adjustments/cancels
Tracking policy for claims in medical review or appeals
Tracking for Medicare secondary payer claims
Education
Subscribing to Listservs
Contractor calls
CMS Open door forum
33
34. A/R MANAGEMENT
Insurance Follow up
Clearinghouse
Payer website
Involving provider rep. when needed
Involving state insurance commissioner when needed
For Medicare replacement plans involving your local CMS
office managed care plans division when needed
Staying up on contracts and addendums
34
35. A/R MANAGEMENT
Accountability
Scheduling consistent aging meetings between billing and
executive leadership
Deadlines for month end close
Maintaining accurate A/R
Updating Medicare/Managed Care Rates
Part A October
Part B January
Part A coinsurance January
35
36. A/R MANAGEMENT
Maintaining accurate A/R
Policies/Procedures for contractual adjustments and write
offs
Authorizing staff responsible for making entries
Setting a dollar threshold for levels of approval
Designating a person to review entries for accuracy
Determining reports that should be reviewed monthly
to catch all adjustment/write off entries
36
37. A/R MANAGEMENT
Sequestration
2% reduction effective April 1, 2013 DOS
Medicare A and B
Managed Care depending on payer
Does not impact coinsurance portion of payment
Part B MPPR
Practice expense reduced by 50% effective April 1, 2013
DOS
37
38. A/R MANAGEMENT
Understanding Medicare Remittance Advice
Non covered charges Part A= typically sequestration
Non covered charges Part B= MPPR, sequestration, charges
rejected for missing modifiers
Verify all services were covered prior to adjusting A/R
Link to universal RA codes
http://www.wpc-edi.com/reference/
38
39. A/R MANAGEMENT
Medicare Reimbursable bad debt
Only Part A coinsurance is Exhibit 5 eligible
Coinsurance related to Medicare replacement plans
does not count
Develop a system for tracking throughout the year
Routine write offs
Keep a file for copies of support such as payer denials,
copies of private statements, etc.
39
40. A/R MANAGEMENT
Medicare Reimbursable bad debt
Non dual eligible (Private pay due)
Must have been billed at least 3 times
“Reasonable and Customary attempts” to collect must
have been taken and documented
Debt must remain unpaid more than 120 days from the
date first billed
Write off date must be in applicable cost report year
Payment effective with FY-2013 reduced to 65% (63%
after sequestration)
40
41. A/R MANAGEMENT
Medicare Reimbursable bad debt
Dual eligible- Medicaid non payment varies by state
Proof of non payment- copy of remittance advice with
correct denial reason code for legislative non payment
Denial for billing error or timely filing would not
suffice
Write off date must be in applicable cost report year
Payment reduction
FY 2013 88% (86% after sequestration)
FY 2014 76% (74% after sequestration)
FY 2015 65% (63% after sequestration)
41
43. THANK YOU
FOR MORE INFORMATION // For a complete list of our offices
and subsidiaries, visit bkd.com or contact:
Name, Credentials // Title
email@bkd.com // 888.888.8888
Notes de l'éditeur
{"26":"The COT is required whether the therapy intensity goes up or down. The ADLs do not impact the need for a COT.\n"}