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by Mark Kander
Skilled Nursing Facility (SNF) Medicare payment rules have an impact on services provided by speech-language pathologists and audiologists. Medicare terms basic to the understanding of billing in this provider setting include Part A and Part B coverage and "consolidated billing."
Coverage Definitions
- Part A coverage. A SNF resident is covered under Part A for 100 days if admitted within 30 days of discharge from a hospital stay and requires skilled nursing services daily or rehabilitation services at least five days per week.
- Part B coverage. These patients are typically admitted as Part A inpatients and have exhausted the 100-day benefit. A Medicare patient seen in a SNF's outpatient rehabilitation clinic also has Part B status.
Consolidated Billing
Consolidated billing is different for Medicare Part A and Part B:
- Part A services are billed to the SNF rather than to the Medicare fiscal intermediary. This rule applies to all non-physician services for Part A residents because the SNF receives a flat daily rate (based on the resident's "resource utilization group" or RUG) to cover all nursing and rehabilitation needs.
- Part B services are billed through the SNF to Medicare. This rule applies only to speech-language pathology, physical therapy and occupational therapy services rendered to Part B patients. All other services may be billed directly to Medicare. The rule helps the Centers for Medicare and Medicaid Services (CMS) monitor data related to rehabilitation because the services are not being billed by a multitude of separate providers. In other words, it helps eliminate double billing.
Payment for speech-language pathology services are negotiated between the practitioner (or rehabilitation contractor) and the SNF, whether the patients are Part A or Part B. An audiologist must negotiate rates for services to Part A patients but can bill Medicare directly for services to Part B patients. Medicare does not govern the terms of contracts between practitioners and SNFs.
In the negotiating process, it is helpful to know that the Medicare Physician Fee Schedule identifies the amount paid for each evaluation, treatment session or diagnostic test. The fee schedule is available on ASHA's Web site.
Billing for Hospital Services
When a SNF resident is seen as a hospital outpatient, Medicare billing procedures are still dictated by the patient's SNF status. Billing for a modified barium swallow study (MBS) is a good example because the MBS consists of a radiology procedure (CPT 74230) and a speech-language pathology procedure (CPT 92611).
As Table 1 indicates, for Part B residents the speech-language pathology procedure is subject to consolidated billing whereas the radiology procedure is not. Let's also assume that the SNF resident received audiology testing when at the hospital for the MBS. Table 2 describes how the billing would be handled by the SNF and the hospital.
For more information contact Mark Kander , ASHA's director of health care regulatory analysis at mkander@asha.org or through the Action Center at 800-498-2071, ext. 4139.
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