Know Whom to Bill for Services to Nursing Home Patients

If your practice sees patients in nursing homes, you need to know the rules for billing Medicare for their treatment. TrailBlazer Health Enterprises, the Texas Medicare carrier, has reported a high volume of calls and overpayments because physicians are confused about Medicare's rules for skilled nursing facility (SNF) consolidated billing .

Remember these important points:

  • Under the consolidated billing requirement, the SNF, or nursing home, bills Medicare for the entire package of care that residents receive during a covered Medicare Part A nursing home stay. The SNF also bills Medicare for physical, occupational, and speech therapy services received during a noncovered stay.
  • The Medicare rules exclude a limited number of services from consolidated billing, including physicians' professional services, which Medicare pays for separately.
  • Physicians should not bill Medicare Part B for services included in the consolidated billing requirement; they should file to Medicare Part B only those services that are excluded from SNF consolidated billing.
  • Physicians may bill the nursing home directly for those services included in SNF consolidated billing only if the physician is in a business relationship with the nursing home. The nursing home, which normally bills Medicare Part A once a month, then will bill Part A for that service.
  • Medicare Part B is notified that a patient is enrolled in a covered Part A stay once Part A receives a claim for services rendered by an SNF.

To help prevent denials and overpayments, follow these guidelines from Skilled Nursing Facility Consolidated Billing Manual ( PDF ), a downloadable TrailBlazer publication:

  1. During the patient screening process, ask whether the patient is a resident of a nursing home.
  2. If yes, contact the nursing home and ask if the patient is in a covered Part A stay.
  • If the patient is in a covered Part A stay, determine if the nursing home has a contract with an entity to provide the services that fall into the consolidated billing guidelines.
  • If the nursing home does have such a contract, refer the patient back to the nursing home for those needed services.
  • If the nursing home does not have such a contract, you must develop a business relationship with the nursing home and bill the nursing home for services you provide that are included in consolidated billing.

Example: Billing
A physician provides a chest X-ray (code 71010) to a patient. She would bill Medicare Part B for the professional component only, using the -26 modifier (71010-26).

If the physician has a business relationship with the SNF, her office would bill the technical component directly to the SNF (71010-TC).

Note: If the nursing home has a contract with another entity to provide the technical component or if the physician does not have a business relationship with the nursing home, the physician's office will not receive payment for this service. The patient is not liable, and the physician should not file this portion of the X-ray to Medicare Part B.

Example: Overpayment
Before the SNF submits its monthly filing to Medicare Part A, a physician bills Medicare Part B for services that are subject to consolidated billing. At this time, Part B is not aware that the patient is in a covered Part A stay. Therefore, Medicare Part B could reimburse the physician for the services subject to consolidated billing.

Once the SNF files for its services to Medicare Part A, records are sent to Medicare Part B indicating that the patient is in a covered Part A stay. Medicare then researches records for the time period that the patient is enrolled for any payments made on services subject to consolidated billing. In this way, Medicare will identify overpayments and recoup the overpaid amount from the physician.

Example: Denial
After the SNF has filed its services to Medicare Part A, a physician bills Medicare Part B for the total component of an X-ray, a service that is subject to consolidated billing.

Because the Medicare national records have an SNF episode recorded, Part B will deny the total component of the X-ray. Part B will reimburse the physician only after he has refiled his claim for the professional component of the X-ray only. 


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