Consolidated billing: Fact or fiction?

Dec 27, 2018
The Bottom Line

Test your CB knowledge with the following fact or fiction scenarios:

Fiction

A SNF does not need to list all the CB-included services it renders on the consolidated bill’s claim form because the provider won’t be reimbursed for each specific service anyway.

Fact

Yes, the SNF does. Otherwise, the provider is out of compliance with Medicare’s rules for consolidated billing—a lapse that could result in the recoupment of any identified overpayments.

Fiction

All outpatient services the SNF Part A beneficiary receives are separately billable to Part B.

Fact

If a SNF Part A beneficiary goes anywhere other than a hospital outpatient department to receive a category I service, the SNF must account for the item on the consolidated bill and pay for it out of the resulting PPS rate lump sum.

Fiction

Claims for category I services provided to a beneficiary in the midst of a Part A SNF stay are excluded if the hospital that provides them owns the free­standing clinic.

Fact

What matters here is the Medicare provider number. A clinic that bills Medicare using the hospital’s provider number is considered a hospital outpatient department and will therefore have to bill separately for the service it rendered to the beneficiary during the Part A SNF stay. However, if the clinic uses a different Medicare provider number than the hospital, it is considered a freestanding clinic, and the service must therefore be included in the SNF’s consolidated bill.

Fiction

EPO and Aranesp® are always excluded from consolidated billing for a SNF Part A beneficiary.

Fact

EPO and Aranesp are excluded from Part A consolidated billing only when provided in conjunction with dialysis to end-stage renal disease (ESRD) beneficiaries and billed by an approved renal dialysis facility or outside dialysis supplier. On the other hand, these drugs are included in consolidated billing whenever they are given to either:

  1. An ESRD beneficiary directly by the SNF

  2. A non-ESRD beneficiary

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