Consolidated Billing and the ASC

MedLearn Matters MM6702 describes a new edit involving consolidated billing (CB) and facility services provided in an ambulatory surgery center.

Consolidated billing is defined as follows: Medicare Part A covers nursing facility stays under very limited conditions; usually only after discharge from a hospital visit lasting at least three days and only for the first 100 days (a short period of time) after admission to the SNF. For those patients who are in this situation, special rules apply to some ophthalmic services. Since 1998, the Social Security Act requires skilled nursing facilities (SNFs) to bill Medicare for the entire package of services that their residents receive during the course of their covered Part A stay. An exception is made for certain excluded items and services, including physicians’ professional services (e.g., exams) and the professional component of physician diagnostic services submitted with modifier -26 (e.g., A-scan interpretation).

According to the change request described in the MLM, ASC facility services provided after January 1, 2008 are subject to consolidated billing rules and must be billed to the SNF and not to Medicare. ASCs will likely see requests for refunds for claims paid after January 1, 2008 by Medicare when it is determined that the services fall under the SNF CB requirement.

The CMS transmittal can be found at http://www.cms.hhs.gov/Transmittals/downloads/R1911CP.pdf