Each federal fiscal year, the payment rates for Skilled Nursing Facilities (SNF) are increased by the government, in accordance with the SNF market basket index, which takes into account prevailing conditions for medical treatments. The overall system under which payments are made is known as the Prospective Payment System (PPS), and this system is continually adjusted for case mix and for the geographic differences in wages which may be in effect for certain areas of the country. It also considers the current costs of providing routing SNF medical services such as ancillary and capital-related costs. 

SNF consolidated billing

The consolidated billing requirement puts the responsibility on the SNF for the complete package of care which residents receive during any covered stay at the facility, as well as the physical, occupational, and speech therapy services which are provided during a non-covered stay. There are a few services which are specifically excluded from this billing schedule, and are payable separately.

Each new fiscal year, the consolidated billing requirements for skilled nursing facilities are carefully reviewed, and this includes billing for occupational therapy, physical therapy, and speech language pathology services. Also reviewed are any specific exclusions which are billable separately including some services which are considered to be “high cost, low probability”, as identified by the Healthcare Common Procedure Coding System (HCPCS).

These categories include customized prosthetic devices, radioisotope services, chemotherapy administration services, and chemotherapy items. The codes which are excluded from the consolidated billing all represent situations which could have major financial impact, because their costs greatly exceed the skilled nursing facility PPS payments. 

SNF excluded services

There are several types of services which are specifically excluded from the skilled nursing facility consolidated billing agreement. These services would be separately billable to part B Medicare when furnished by an outside supplier to any resident of a skilled nursing facility. It will still be necessary for these excluded services to contain the SNF’s Medicare provider number, when they are furnished to SNF residents. Here is a listing of most of the excluded services which would have to be handled by separate billing:

• certified nurse midwives
• qualified psychologists
• certified registered nurse anesthetists
• physician services furnished to SNF residents which are not subject to consolidated billing, and must therefore still be billed separately to the part B carrier
• physician assistants working under the supervision of a qualified physician
• hospice care related to some terminal condition of a resident
• ambulance services which transport a patient to the skilled nursing facility, or from the facility after discharge
• all those services described in section 861(s) of the Social Security Act
• nurse practitioners or clinical nurse specialists who are collaborating with a qualified physician.

Physician “incident to” services

The consolidated billing agreement does exclude those types of services described above, but it does not exclude those services known as “incident to” services which are furnished by a third party as an incident to the professional service of the practitioner. These kinds of services furnished by others to residents of a skilled nursing facility are subject to the consolidated billing agreement, and must therefore be billed to Medicare by the SNF itself. Here is a listing of some of those “incident to” services:

• some venous and lymphatic procedures
• angiography
• magnetic resonance imaging
• emergency services
• radiation therapy services
• cardiac catheterization
• computerized axial tomography
• ambulatory surgery which requires usage of an operating room.

2021 Skilled Nursing Facility PPS unadjusted federal rates per diem 

The most important of the services offered by an SNF, along with the federally mandated payment schedules are listed below:

• Physical Therapy for urban centers – $62.04, and for rural centers – $70.72
• Occupational Therapy for urban centers – $57.75, and for rural centers – $64.95
• Speech-Language Pathology for urban centers – $23.16, and for rural centers – $29.18
• Nursing for urban centers – $108.16, and for rural centers – $103.34
• Non-Therapy Ancillaries for urban centers – $81.60, and for rural centers – $77.96
• Non-case mix adjusted for urban centers – $96.85, and for rural centers – 98.64.

The Center for Medicare and Medicaid Services (CMS) reviews all relevant factors, including the historical information, before establishing the initial federal base rates for billing. These rates are periodically updated for inflation and other factors which have a bearing on the billing process, so that the fairest payment rates can always be in effect, and allow SNF’s to remain economically sound.

In this case, the CMS has finalized a market basket increase for 2021 of 2.2%, based on historical data from 2020 as well as a forecast provided by IHS Global Insight. This forecast takes into account the expected increases for routine, ancillary, and capital-related expenses, in order to arrive at the best possible projection of costs and expenses which are likely to be in effect for the coming year.

In standard medical practice, allergy testing cannot be performed on the same day as allergy immunotherapy, and this means that the two different billing codes should not be reported together. The MPFSTB fees for allergy testing services must be billed using codes 95004 through 95078, and these are all established for single tests.

For this reason, the number of tests administered must always be shown on any billing claim. As an example, if a physician performs 25 percutaneous tests involving allergenic extracts, the appropriate billing code would be listed and then 25 would have to be listed in the units field. Thus, the Medicare carrier would multiply the payment for one task times the number of units in order to calculate the total payment reimbursement. This same methodology applies whether the allergy testing is by scratches, punctures, or pricks.

Non-covered services

Allergy testing is always covered provided that clinically significant symptoms exist, and that traditional therapies have already failed to achieve results. Allergy testing will include the performance, reading, and evaluation of mucous membrane and cutaneous testing, as well as an evaluation of patient history including immunology. It will also include the physical examination which decides on antigens which are to be used, and a complete interpretation of all results.

When allergy testing is necessary, the preferred method to use would be standard skin testing, and each of these tests must be billed as one unit of service for each procedure code. This must not exceed two strengths for any given unique antigen. Saline controls and histamines are allowable and these can be billed as two antigens. The total amount of antigens should be specific to each individual patient, based on their history and their exposure to the environment.

Here is a partial listing of those services which are specifically excluded from allergy testing billing:

• Subcutaneous provocative and sublingual intracutaneous and neutralization testing for food allergies must be excluded from Medicare coverage, since current evidence does not support their effectiveness
• challenge ingestion food testing has not been shown to be effective for diagnosing depression, respiratory disorders, or rheumatoid arthritis. For this reason, its usage is not considered to be necessary or reasonable, and therefore is not included in the payment program
• cytotoxic food tests are excluded because current evidence does not support the fact that they are either safe or effective, and must therefore remain outside the payment program.

Hospital inpatient claims

CMS currently differentiates individual allergy tests from multiple allergy tests by assigning the two services to different APCs. CMS assigns single allergy tests to APC 0381, which has been newly established for that purpose, and multiply allergy tests are included under APC 0370. Therefore, hospitals must report charges for the CPT codes describing single allergy tests to reflect charges on an individual test basis rather than per visit, and will be obliged to bill the appropriate number of units with these CPT codes, so that all tests provided can be included on the claim.

Allergy coding guidelines 

Allergy testing should not be performed on the same day as allergy immunotherapy according to standard medical practice. Instead, allergy testing must be executed before immunotherapy, so as to identify the offending allergens. CPT codes for immunotherapy and allergy testing are not reported on the same service date, unless the physician performs both services on that same day. Physicians should not be reporting allergy testing CPT codes for potency testing prior to the carrying out of immunotherapy.

Confirmation of potency of any allergen for immunotherapy is considered to be an inherent component of immunotherapy. Allergy testing is a major component of rapid desensitization kits, and is therefore not to be reported separately. Whenever percutaneous or intracutaneous single tests are performed on the same service date, using CPT codes 95004 or 95024, and CPT codes 95017, 95018, and 95027 respectively, both the sequential test and single test codes can be reported, provided that the tests are for different allergens.

The unit of service which must be reported is the number of separate tests, and a single test for the same dilution of an allergen cannot be reported separately on the same service date. As an example, if a single test for an antigen is positive, and a physician then performs a sequential test with two additional dilutions of the same antigen, the physician would only be able to report one unit of service for a single test code, in addition to the two units of service for sequential and incremental test codes.

When CPT code 95052 is used on photo patch tests, the procedure must consist of an allergenic substance which is applied to a patch, and which is then exposed to normal lighting. This particular type of test must not be unbundled by reporting CPT code 95044 (patch or application test) plus CPT code 95056, which is a photo test. The appropriate test code to use for this kind of testing is 95052. Evaluation and management codes which are reported with allergy immunotherapy or allergy testing can only be used when a separately identifiable service is executed. In such cases, modifier 25 must be utilized.

For many people, telemedicine works as a cost-effective alternative to the traditional face-to-face appointment. It helps some, such as elderly patients and those with disabilities better navigate the obstacles that may otherwise make it hard to see their doctor. For all patients, it tends to lend itself to better satisfaction and convenience.

Despite the fact that telemedicine is becoming more common, many health care providers still have trouble with reimbursement. Getting used to new rules for billing and coding procedures properly in order to get paid appropriately can take time and effort. Add to that payer differences in telemedicine coverage and policies and it can become even more complicated. Here are a few things to keep in mind about billing for telemedicine.

Ensure that telemedicine is covered by the payer

A lot of trouble is caused by the mistake of neglecting to submit claims without first checking if the payer covers telemedicine services. Before providing those services, it’s recommended to call the insurance provider for that verification. If the provider assures you that they do, be sure to document it as it may be helpful in the event of a denied claim later.

Know the specific insurance provider’s policy

As mentioned, different payers have specific policies regarding telemedicine, and you should take the time to verify this as well. This can include making sure the specific services you are covering are covered, whether it applies to the type of telemedicine you are using, any qualifying criteria, and any restrictions for telemedicine coverage.

The major payers, such as Medicare have their own restrictions and rules for reimbursement. In that case, the patient can only be reimbursed for telemedicine services if they are seen at an authorized site like a skilled nursing facility, public hospital, doctor office or certain private hospitals. The patient has to also be seen by a nurse, doctor MD, or clinical psychologist and the service itself must be within the regularly covered codes. The facility providing the telemedicine must also be located in a Health Professional Shortage Area (HPSA) and not within a Metropolitan Statistical Area (MSA). 

Meanwhile, Medicaid approves reimbursement for telemedicine on a state-by-state basis, with the policy differing within each state as well. For instance, some may cover real-time visits only, while others cover remote monitoring services as well. Private payers tend to cover telemedicine more widely, but again, the reimbursement policies can differ between each individual payer, so care must be taken to get the detail you need on their policy before submitting a claim.

Tips to help you with better billing and coding for telemedicine

As the points above have hopefully detailed, telemedicine billing and coding can be a source of some confusion and care must be taken to ensure that you’re getting the right amount of reimbursement for the services that you provide. As such, the following tips can help you ensure that you’re protecting yourself.

Be sure to document the services you provide

Documenting time spent is crucial, just as it is with all other kinds of coding. You must document the time spent for each encounter in telemedicine billing but ensure that you account for that time accurately. For instance, with some codes, the only time that counts is the face-to-face time you spend with the patient or caregiver when deciding which level of service accurately describes the appointment. 

Know about the 95 Modifier

With the video component of telemedicine encounters, you can also ensure it is accurately documented by adding the 95 modifier to the standard CPT code for the service. However, while this modifier can be used for the video component of live telemedicine services, it should not be used for any encounters that are asynchronous like emails, radiograph studies, or video services that do not involve both parties being live and actively involved at the time that the service is provided.

Don’t forget about any devices used as part of the treatment

Telemedicine assessments often include the use of peripherals and wearable devices. For instance, you may use spirometers, thermometers, glucose monitors, oxygen saturation monitors or blood pressure monitors. Make sure you document the use of any of these devices when coding as they will support the CPT code you use to bill. If you do not, you can end up having a bill rejected because your documentation doesn’t support the service you are billing for.

Billing with telemedicine doesn’t have to be so difficult

Though telemedicine billing may seem somewhat complicated, don’t let that get in the way of the benefits that it can provide. The ability to monitor your patients remotely and provide services without having to always be face-to-face can be greatly convenient for your patients, improving their outcomes as well as their satisfaction with your services.

With Medicare continuing to support and reimburse more and more telemedicine services as time goes on (and many other payers following suit if not surpassing that coverage) we can expect to see the service become more and more widely used in the 2020s. Ensure your practice is taking advantage of this new technology with help from teams like Medical Healthcare Solutions.

Amidst the outbreak of the new coronavirus (COVID-19), many medical institutions are unaware of what happens with regards to coronavirus medical billing. What gets covered in this situation? Are there any things you need to put in place? 

Below, we’ve listed some of the most frequently asked questions surrounding this topic. Information is taken from the CMS, and it is accurate as of March 5th, 2020.

Can COVID-19 tests be billed?

Yes, your healthcare institution can bill for tests for COVID-19. Typically, Medicare Part B will cover medically necessary clinical diagnostic laboratory tests when they’re ordered. As such, you can bill Medicare for these tests when they’re performed. 

However, this can only be done starting in April. CMS outlined a new Healthcare Common Procedure Coding System (HCPCS) that comes into effect in April and can be used for any tests that happened after February 4, 2020. 

Companies need to bill for these tests using the code U0001 – if the tests are developed by the CDC. For any tests that aren’t, the code U0002 must be used. 

Also, other insurers may cover COVID-19 tests, so they can be billed depending on what coverage the patient has. 

Can new drugs for COVID-19 be billed if they are created?

Any new drugs created to treat COVID-19 are covered under Medicare Part B. This includes any new antiviral drugs on the market. They will be paid by the Medicare Administrative Contractors until a new code is created. 

Some new drugs may be covered under Medicare Part D. In which case, they can be billed to the beneficiary’s Part D plan. 

Does Medicare cover the costs of a doctor or non-physician practitioner to furnish care in a beneficiary’s home?

Many people suffering from COVID-19 will require at-home care due to a reduction in available hospital beds. As such, Medicare does pay for many of the services a doctor of NPP will have to provide in the home. 

This includes evaluation and management and many other services furnished in a beneficiary’s home. It’s also possible to bill for other services that aren’t face-to-face, provided they’re used to help manage the patient’s condition. This primarily includes remote patient monitoring services and communication services used to help the patient. 

Will Medicare cover the costs of a doctor, NPP, or nurse using technology to communicate with a patient?

Many modern healthcare technologies can be expensive to use. As such, Medicare does cover various services that offer brief communications between patients and practitioners. Things that are covered include telephone calls, video calls, e-mail, online patient portals, and many more. 

Does Medicare allow billing for care provided at alternative care sites (ACSs)?

During the COVID-19 outbreak, it’s possible to reach a state of emergency where hospitals can no longer provide support for patients on the main hospital premises. As such, an ACS may be set up to continue treating sick patients. Hospital beds are reserved for the critically ill, so temporary sites can be set up in school gymnasiums, etc. 

Hospitals can add a remote location that offers inpatient services and file an amended Form CMS 855A with its Medicare Administrative Contractor. Provided the ACS fits all the requirements, then any treatments carried out at this location can be billed. 

Will hospitals that are paid by Medicare through the Inpatient Prospective Payment System (IPPS) continue to be paid this way?

IPPS hospitals will continue receiving normal payment during the COVID-19 outbreak. Some hospitals have questioned whether or not there is a special Diagnostic Related Group (DRG) for this virus, but there is not. If you are paid through the IPPS, then carry on as normal. 

Will Medicare pay for any vaccinations of Medicare beneficiaries?

As there is currently no vaccine available, this isn’t something to be concerned with, in the immediate future. However, the current law stipulates that when a COVID-19 vaccine is available, Medicare will cover it under Part D. Every single Part D plan will have to cover the vaccine when it is released. 

Does Medicare Part B cover a 90-day supply of drugs if a pandemic occurs?

COVID-19 has officially been named a pandemic by the World Health Organization. As a result, many hospitals and healthcare institutions will need to order a greater-than-30-day supply of drugs for patients. This is to cope with the increased demand and rise of patients entering the hospital. 

The current laws say that local Medicare Administrative Contractors (MACs) decide which drugs need to be ordered in or not. This is based on how necessary they are, how many patients need them, and much more. But, if orders are made for a 90-day supply of drugs, then they will be covered under Medicare Part B. 

The only exception is immunosuppressive drugs, which are generally limited to a 30-day supply. In special-case scenarios, Medicare Part B might cover a larger supply, though this is for extremely rare instances where a patient desperately needs this supply. 

How will ambulance payments be handled during the COVID-19 outbreak?

Ambulances will be more in-demand than usual during the coronavirus outbreak. As such, there are lots of questions surrounding the medical billing side of things. 

Right now, if an ambulance crew provides treatment but does not transport anyone or furnish the treatment from their ambulance, then these services cannot be billed to Medicare. These can only be billed if the patient is transported in the ambulance or equipment from the ambulance is used. 

Medicare can also be billed for all ambulance transportation costs during the COVID-19 outbreak. This will be done through the usual payment guidelines and relates to patients that are transported from home to a hospital, or from one hospital to another, or even from one hospital to a separate medical facility. 

If any additional equipment is required when transporting patients – such as a portable oxygen container – then this can also be covered and billed by Medicare. If the transport is already a Medicare-covered service, then it automatically will be supplied with the equipment through Medicare. If it isn’t, then payment under Medicare Part B can be made to cover the costs. 

For further details on coronavirus medical billing, feel free to read through the entire CMS document and any further publications released by the authority.