“This past summer, one of my patients who was suffering from a diabetic foot ulcer was admitted to a skilled nursing facility (SNF) following a hospital discharge. During her admission to the SNF, I continued to care for her in my office, including ulcer debridement and radiographs. Medicare is denying payment for her ulcer debridements (CPT 97597) as well as the technical component of her radiographs (CPT 73630-TC) on the grounds that “all SNF Part A inpatient services are paid under a prospective payment system (PPS)” and that “services that are considered within the scope or capability of SNFs are considered paid in the PPS rate.” In other words, Medicare considers the care that I rendered to be bundled with the payment to the SNF for admission, and therefore the SNF should have been doing it themselves, and that if I want payment I need to bill the SNF since they–in Medicare’s view–outsourced the ulcer care to me. While I fully expect the SNF to balk at any requests for payment from me, and I believe it might still be worth my time to appeal to an Administrative Law Judge, I would like to know if anyone has experienced this? In the future, if I am going to care for the ulcers of my patients when they are admitted to SNFs, is there anything I can arrange with the SNF or with the patient to ensure I am compensated for their care?”
Unfortunately, despite all of the care that the above physician provided to his/her patient when she was seen and treated in the physician’s office, based upon the fact that the patient was previously admitted to a Skilled Nursing facility (ie. SNF), Medicare was correct in denying payment. When a patient is admitted to a SNF, which can be for up to 100 days, all of the services that are provided are reimbursed by Medicare Part A as part of a consolidated billing arrangement or as the physician was informed, a Prospective Payment System or PPS, which is essentially a reimbursement method used in which a fixed, predetermined amount is allocated for treating patients with a specific diagnosis. Unfortunately, the treatment of the patient’s diabetic foot ulcer and the technical component of the X-ray services that were provided fall under this umbrella. The fact that the patient was treated by the physician in the office has no bearing on the decision. The patient was still admitted to the SNF.
The only way that reimbursement can be achieved when a patient is in a SNF would be to approach the SNF in advance of treatment and inquire whether or not they will reimbursement you for the services that you would like to provide to the patient. The likelihood of this being successful is not great. Remember, these services are paid under the Medicare Part A PPS rate. It is extremely unlikely that reimbursement will be achieved “after the fact” by submitting a bill/statement to the SNF.
As far as appealing this situation before an Administrative Law Judge (ALJ), the decision is based upon written rules and regulations, not upon an opinion. Therefore, I do not think that it would be worth the physician’s time and effort to follow through with this appeal.
You can reference the following source of information: MLN Matters Number: SE0431 – Skilled Nursing Facility Consolidated Billing.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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