I recently posted the following question and was asked to post the responses:
I recently provided immediate post op BK cast procedures to two patients who are now in skilled nursing facilities. Both are in the SNFs under Medicare part A. I requested POs on both patients and was told that I had to bill Medicare B for the cast changes because according to the list that the SNFs have from medicare,
http://www.cms.hhs.gov/manuals/104_claims/clm104c06snfhelp.pdf
the following L codes are to be billed directly to Medicare, even though the patient is in the SNF under Medicare part A: L5400 to L5460, various post op plaster procedures.
The reference states that the SNF cannot bill Medicare for reimbursement for these codes.
I believe that means that these codes are simply part of the PPS package that the SNF gets paid for the patient and that they cannot bill Medicare for additional money if I provide that service in the SNF. They still have to pay me but cannot request additional payment from Medicare for paying me. The SNF says that what the reference means is that since
they cannot be reimbursed, it is my responsibility to bill Medicare. I participated in the AOPA SNF phone conference November 30, and in the list of items that were excluded from SNF PPS billing (excluded items can be billed to Medicare when the patient is under part A) these codes (L5400 to L5460) are not on the list and therefore must be billed to the SNF. So, do I bill Medicare? Or what do I tell the SNF to “help” themunderstand this better and pay me.
Here are the responses:
I’ve run into this PPS dodge before and also just recently on orthotic and prosthetic patients. I call it the Pick want you want to Pay for System. You are probably not going to get the skilled nursing facility to pay for these services even if you, as you have done, show them the regulations. I suggest that you just eat it (after all 8-10 rolls of plaster on each with distal reticulating pads and sterile socks is costing you about $50 each) but be gracious about it and position yourself to provide the preparatory and definitive prostheses when your two patients come out of Medicare Part A status (usually 90 days). Be patient. Don’t win this battle and lose the war. Hope this helps.
Everyone should be aware that we still can bill the DMERC for a prep prosthesis even if the patient is in an SNF under Med A. Socks must be billed to the SNF.
If you fit a prefabricated post-op such as the Aircast Air-Limb or the
Flo-Tech you can use L5535 which you can bill directly.
It may be helpful for you to print the section of the Medical Review Policy in question and provide it to the business office at the nursing home. This may help them understand that the nursing home is responsible for the codes.
It is my understanding that the L-codes in question are included in the payment to the SNF unit if a patient is in a part A stay. Anytime during the part A stay prior to the day of discharge, and the patient uses the prosthesis for medically necessary inpatient treatment or rehabilitation, the claim must not be submitted to the DMERC. Refer to your local Region(s) local medical review policy for lower limb prosthesis.
Here again, during the part A stay, if a prep or difinitive prosthesis is provided, it can be billed to the DMERC. Socks and orthotic devices must be billed to the SNF.
And the most helpful response was from Kathy Dodson at AOPA:
You don’t bill Medicare. The chart that the SNFs are using as a reference is in error. We have already made Medicare aware of this and they say they will correct it, but we don’t know when. In the meantime, we have a letter from CMS saying that these items are the SNF responsibility. Send me your fax and I’ll send it to you. We will also post it on our web site shortly.
Kathy
Not only did she fax a copy of the letter to me, but this issue was addressed in the most recent AOPA in Advance. Look on the AOPAnet web site for a copy of this letter that you can send to any SNF that questions your billing of post op casts to them. Thanks Kathy.
I did notice that some of the respondents believed that we could not bill the DMERC for either a prep or a difinitive prosthesis when the patient is in the SNF under part A. This is wrong. Even if the patient is in the SNF under part A, and anytime during the part A stay, we can bill Med B for the prosthesis. Just not the post op casts, or any orthosis, or diabetic shoes. These last items must be billed to the SNF during the part A stay (unless provided on the last day of the stay for training only).
Thanks to everyone for your replies.
Karl Entenmann, CPO
Preferred O and P
Federal Way, WA
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