Running a skilled nursing facility (SNF) means you’ve got loads of responsibilities, but on top of patient care, you’ve got the consolidated billing requirement to deal with. In short, Medicare bundles almost every medical service a resident needs into a single per-diem payment that the SNF has to bill. 

That sounds like a fairly tidy and manageable process, but you’ve also got to deal with the yearly code updates and the rules for who can bill Medicare directly. 

Today, we’ll break down the big pieces simply, so you can keep the focus on patient care instead of paper-chase. 

How Does the SNF Consolidated Billing System Work?

Everything a resident uses during a covered Part A stay gets noted. So, for example, if a visiting cardiologist orders a stress echo, the service gets noted, and the facility bills for it even though the cardiologist provided the physician’s professional service. 

When the stay switches to Part B – say, after skilled coverage exhausts – only therapy services like speech therapy services received keep flowing through the SNF’s claim. 

Other supplies may bill Medicare directly once the covered days end, but most still have to list the SNF’s provider number.

Why Did CMS Create a Single Bill?

1. Prevent duplicate payments.

2. Encourage facilities to coordinate care tightly.

That coordination is vital here: CMS projects Part A payments to SNFs will rise another 4.2%, or roughly $1.4 billion, for fiscal year 2025. 

Which Major Categories Sit Inside the Bundle?

– Everything from therapy and nursing to labs and most drugs stays inside.

– Routine supplies and room-and-board costs also get bundled.

Because these categories are so broad, the facility even absorbs emergency outpatient hospital services if the resident returns before midnight. And yes, even the ambulance services that transport them back fall under this category as well.

What Services are Specifically Excluded and Can Still Be Billed to Medicare Directly?

– Dialysis services for ESRD, including related ambulance trips.

– Certain chemotherapy administration services and some customized prosthetic devices, as well as some radiology procedures.

CMS publishes an annual list of HCPCS codes that describe services excluded from SNF CB, and your Medicare Administrative Contractor (MAC) updates its edits every quarter. 

Are There Gray Areas Here?

Absolutely. For example, a physician’s visit becomes bundled if it happens on-site during the covered stay, but the same doctor can bill separately for off-site follow-ups. 

Likewise, durable medical equipment is generally included unless it is a customized prosthetic device that was molded elsewhere. Again, if you’re in doubt, just check both the code list and your MAC’s latest newsletter.

Why Should a Small Practice Outsource Billing to PMN?

Every hour that you’re spending reverse-engineering a rejected claim is an hour you could spend with patients or staff. That’s what you got into healthcare for. Our team at PMN has spent more than 20 years living and breathing Medicare and medicaid services regulations – we:

– Scrub claims before submission

– Chase documentation

– Speak fluent payer

– Help denials drop 

– Let cash reach your account sooner

Practices that hand off their medical billing and coding to us see huge improvements in their accounts receivable turnover – not to mention get fewer compliance headaches. 

Interested in hearing more about how PMN can keep your practice thriving? Learn more about our medical billing and coding services by getting in touch with our staff at (949) 215-5055 or by visiting our office for an in-person chat in Laguna Hills, Orange County, California! 

What Does Compliance Look Like Day-to-Day?

– Reconcile your census against claims weekly and flag mismatches early.

– Keep a cheat sheet of services that are excluded this year, and make sure you keep it near every workstation!

Also, make sure you’re noting details like the date/time and whether an ambulance trip occurred if you send a resident out for dialysis – those details decide who bills. The same process goes for when you’re arranging outside speech therapy or emergency scans. Basically, just document once; bill right the first time.

How do Medicaid Services Intersect with Medicare Billing?

Medicaid often covers long-term custodial care after skilled benefits end, but we still see a lot of states expect facilities to honor the SNF CB edits for dual-eligible residents. Many MAC audits now cross-match state data, so sloppy crossover claims can trigger refunds, which is obviously far from ideal when you’re running a small practice.

How Do You Stay Current with Code Updates?

CMS posts quarterly files that highlight any additions or deletions in the major categories of excluded services. You’d see those spreadsheets easily if you subscribe to your Medicare Administrative Contractor’s listserv.

What’s the Risk of Non-Compliance?

Our audit experience shows that a typical skilled nursing facility (SNF) submits hundreds of lines of medical services every week. Except, when reviewers find that you rolled a HCPCS code for one of the services specifically excluded – say, certain chemotherapy administration services – into the Part A claim, they recoup the entire line plus interest. And it snowballs fast. 

The same happens if you forget to let an outside supplier bill Medicare directly for a customized prosthetic device. You can probably see how that ends up becoming its own full-time job once you multiply that by several payers, so staying alert now definitely beats refunding revenue later.

FAQs

Is Ambulance Transport Always Excluded from SNF Consolidated Billing?

No! Only certain ambulance services – usually those tied to dialysis or initial admission and final discharge – are outside the bundle. In-stay trips for routine labs or imaging generally stay inside, so track the purpose of every ride.

Can I Bill Medicare for Customized Prosthetic Devices Provided to an SNF Resident?

Yes, but only if the item meets CMS’s definition of a customized prosthetic device and appears on the annual excluded-services code list. Standard off-the-shelf prosthetics stay bundled, so verify the HCPCS code and documentation before sending a separate claim.