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Q. How should certain diagnostic tests provided to Skilled Nursing Facility residents be billed?

Patient Financial Services Weekly Advisor, December 21, 2007

Q. How should certain diagnostic tests provided to Skilled Nursing Facility residents be billed?

A. Since CB assigns to the SNF responsibility for billing Medicare for all of the services that a Part A resident receives in the course of a covered stay, payment is included in the SNF Prospective Payment System (PPS) global per diem rate.

The only exceptions are those services that are specifically excluded from this provision. Physician services is one of the service categories excluded from the SNF CB provision and these excluded services remain separately billable to Medicare Part B by the entity actually furnishing the service.

Since many diagnostic tests include both a technical component and a professional component, suppliers need to generate two bills. For example, in the case of diagnostic radiology services such as X-rays, the professional component (representing the physician's interpretation of the diagnostic test) is billed directly to the Medicare Part B carrier.

Because the diagnostic radiology service's technical component is already included within the SNF's global per diem payment for its resident's covered Part A stay, the outside supplier that actually furnishes the technical component would bill the SNF (rather than Medicare Part B) for payment.

The Centers for Medicare & Medicaid Services (CMS) installed electronic edits in 2002 that enable automatic detection of any claims inappropriately submitted under Part B (e.g., for services already included in the SNF's global per diem payment for a resident's covered Part A stay, such as the technical component of diagnostic tests).

Please see Medlearn Matters Special Edition SE0431 for a detailed overview of SNF CB. This article lists services excluded from SNF CB and can be found at: http://cms.hhs.gov/mlnmattersarticles/downloads/se0431.pdf Reference: http://www.cms.hhs.gov/mlnmattersarticles/downloads/se0440.pdf

Source: The Centers for Medicare & Medicaid Services

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