February 4, 2014

Drill Down: Ambulance Claims for SNF-to-SNF Transfers

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RAC Region A contractor Performant posted an automated review issue regarding Ambulance provider claims for Skilled Nursing Facility (SNF)-to-SNF transfers. At issue are claims for SNF-to-SNF transfers with modifier NN (from skilled nursing to skilled nursing) not being separately payable under Part B when the beneficiary is covered under Part A. When the current SNF discharges the Medicare patient to another SNF, then the discharging SNF is responsible for the transportation fees. Ambulance providers should obtain payment from the SNF that transferred the Medicare patient.

Performant references the Centers for Medicare & Medicaid Services (CMS) MLN Matters # SE0433, Skilled Nursing Facility Consolidated Billing As It Relates to Ambulance.

Transfers Between Two SNFs:

When an individual leaves a SNF via ambulance and does not return to that or another SNF by midnight, the day is not a covered Part A day and, accordingly, Consolidated Billing (CB) would not apply. However, a beneficiary's departure from an SNF is not considered to be a “final” departure for CB purposes if he or she is readmitted to that or another SNF by midnight of the same day (see 42 CFR 411.15(p)(3)(iv)). Therefore, when a beneficiary travels directly from SNF 1 and is admitted to SNF 2 by midnight of the same day, that day is a covered Part A day for the beneficiary, to which CB applies. Accordingly, a medically necessary ambulance trip that conveys the beneficiary would be bundled back to SNF 1 since, under 42 CFR 411.15(p)(3), the beneficiary would continue to be considered a resident of SNF 1 (for CB purposes) up until the actual point of admission to SNF 2.”

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0433.pdf

RAC Issues for the Week of February 3 – February 7, 2014:

RAC Region A Performant

Ambulance

  • Skilled Nursing Facility (SNF) to SNF Transfer- JK - Ambulance claims for SNF to SNF transfers (modifier NN) are not separately payable under Part B when a beneficiary is in a Part A covered SNF stay. The SNF discharging the Beneficiary to another SNF is financially responsible for the transportation fees. Ambulance providers should seek payment from the transferring SNF.

RAC Region D HDI

Outpatient Hospital

  • Incorrect Billed Drug and Biological HCPCS Code - Underpayment – Outpatient - Hospitals must report all appropriate HCPCS codes and charges for separately payable drugs, using the correct HCPCS codes for the items used. Medical documentation will be reviewed to determine that the appropriate HCPCS code was billed. (At this time, Medical Necessity will be excluded from this review.)

  • Incorrect Billed Drug and Biological HCPCS Code – Outpatient - Hospitals must report all appropriate HCPCS codes and charges for separately payable drugs, using the correct HCPCS codes for the items used. Medical documentation will be reviewed to determine that the appropriate HCPCS code was billed. (At this time, Medical Necessity will be excluded from this review.)

About the Author

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payers.

Contact the Author

Margaret.Klasa@context4.com

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Margaret Klasa, DC, APN, Bc

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