Skilled Nursing Facility Consolidated Billing

Medicare Part A covers nursing facility stays under very limited conditions; usually only after discharge from a hospital stay lasting at least three days. 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. This is known as consolidated billing (CB). An exception is made for certain excluded items and services. Prior to this payment system for SNFs, Medicare experienced significant problems with duplicate billing to Part B Medicare for services furnished to SNF residents covered under Part A Medicare.

 

This FAQ addresses the following:

  1. What is consolidated billing?
  2. Are there any services that are not subject to consolidated billing rules?
  3. How should physicians bill for the technical component of diagnostic tests performed for these patients?
  4. If no agreement is in place with the SNF, how does the physician collect payment from the facility?
  5. How are ASC facility services handled?
  6. What about injectable medications?
  7. Are there other items we should be aware of that might be subject to consolidated billing?
  8. Is the issue of consolidated billing for SNFs being scrutinized by any reviewing agencies?
  9. Do the consolidated billing rules apply to Medicare Advantage (MA) plans?

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