• The consolidated billing provision places
with the Skilled Nursing Facility (SNF) itself the Medicare billing
responsibility for virtually all services furnished to a resident
of the SNF during the course of a covered Part A stay that is paid
under the Prospective Payment System (PPS). The only types of services
furnished to SNF residents that are categorically excluded from consolidated
billing are the ones specified in a short list of statutory exclusions
at section 1888(e)(2)(A)(ii)-(iii) of the Social Security Act (the
Act), for which an outside supplier can still bill Medicare directly
and receive a separate payment.
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• Since ambulance services (other than those
furnished in conjunction with the receipt of Part B dialysis services--see
section 1888(e)(2)(A)(iii)(I) of the Act) do not appear on this
statutory excluded list, they are subject to consolidated billing
when furnished to an SNF “resident” (see below) during the course
of a covered Part A SNF stay, and are included in the PPS payment that
Part A makes to the SNF. Excluding such ambulance services from
the PPS and consolidated billing provisions would require legislation
to amend the law.
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• 1998 SNF PPS Interim Final Rule: The
preamble to the SNF PPS Interim Final Rule (63 FR 26298, May 12,
1998) clarifies that under the consolidated billing provision, an
ambulance trip is considered to be furnished to an SNF “resident”
if it occurs during the course of an SNF stay, but not if it occurs
at either the very beginning or end of the stay. This policy is
comparable to the one governing ambulance services furnished in
the inpatient hospital setting, which has been subject to a similar
comprehensive Medicare billing or “bundling” requirement for almost two
decades.
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• As explained in the preamble, the initial
ambulance trip that first brings a beneficiary to an SNF is not
subject to consolidated billing, since the beneficiary has not yet
been admitted to the SNF as a resident at that point. Similarly,
an ambulance trip that conveys a beneficiary from the SNF at the
end of a stay is not subject to consolidated billing when it occurs
in connection with one of the events specified in regulations at
42 CFR 411.15(p)(3)(i)-(iv) as ending the beneficiary’s SNF “resident”
status:
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A trip for an
inpatient admission to a Medicare-participating hospital or Critical
Access Hospital (CAH) (however, see discussion below regarding an
ambulance trip made for the purpose of transferring a beneficiary
from the discharging SNF to an inpatient admission at another SNF);
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A trip to the
beneficiary’s home to receive services from a Medicare-participating
home health agency under a plan of care;
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A trip to a Medicare-participating
hospital or CAH for the specific purpose of receiving emergency
services or certain other intensive outpatient services that are
not included in the SNF’s comprehensive care plan (see further explanation
below); or
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A formal discharge
(or other departure) from the SNF that is not followed by readmission
to that or another SNF by midnight of that same day.
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• Ambulance trips to receive excluded
outpatient hospital services: As noted above, the regulations
specify the receipt of certain exceptionally intensive or emergent
services furnished during an outpatient visit to a hospital as one
circumstance that ends a beneficiary’s status as an SNF resident
for consolidated billing purposes. Such outpatient hospital services
are themselves excluded from the consolidated billing requirement,
on the basis of their being well beyond the typical scope of the
SNF care plan. (However, the exclusion of a particular outpatient
hospital service is not invoked on this basis merely because it
does not appear in the individual SNF care plan of the person receiving
the service; rather, the exclusion applies only to those specified
categories of services that, by definition, lie well beyond the
scope of SNF care plans generally).
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Currently, only
those categories of outpatient hospital services that are specifically identified
in Program Memorandum No. A-98-37 (November 1998, reissued as PM
No. A-00-01, January 2000) are excluded from consolidated billing
on this basis: cardiac catheterization; Computerized Axial Tomography
(CT) scans; Magnetic Resonance Imaging (MRIs); ambulatory surgery
involving the use of an operating room; emergency room services;
radiation therapy; angiography; and, lymphatic and venous procedures.
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Since the receipt
of one of these excluded types of outpatient hospital services is considered
to end a beneficiary’s status as an SNF resident for consolidated
billing purposes, any associated ambulance trips are themselves
excluded from consolidated billing as well; thus, an ambulance trip
furnished in connection with the receipt of such services can still
be billed separately to Part B by the outside supplier.
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By contrast, when
a beneficiary leaves the SNF to receive outpatient hospital services
other than the excluded types of services described above and then
returns to the SNF, he or she retains the status of an SNF resident
with respect to the services furnished during the absence from the
SNF. Accordingly, ambulance services furnished in connection with
such an outpatient visit would remain subject to consolidated billing,
even if the purpose of the trip is to receive a particular type
of service (such as a physician service) that is itself categorically
excluded from the consolidated billing requirement.
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• Transfers Between Two SNFs: Under
the regulations at 42 CFR 411.15(p)(3)(iv), a beneficiary’s departure
from an SNF is not considered to be a “final” departure for consolidated
billing purposes if he or she is readmitted to that or another SNF
by midnight of the same day. Such a beneficiary continues to be
considered a resident of the SNF from which he or she departed until
the occurrence of one of the events specified as terminating the
beneficiary’s “resident” status. §411.15(p)(3)(i) specifies the
admission to a second SNF as an event that ends a beneficiary’s
status as a “resident” of the first SNF. As discussed previously,
consolidated billing applies only to services that are furnished
during the course of a covered Part A stay that is paid under the
PPS. Thus, 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
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beneficiary,
to which consolidated billing applies. Accordingly, the ambulance
trip that conveys the beneficiary would be bundled back to SNF 1
since, under §411.15(p)(3), the beneficiary would continue to be
considered a resident of SNF 1 (for consolidated billing purposes)
up until the actual point of admission to SNF 2. By contrast, when
an individual leaves an SNF via ambulance and does not return to
that or another SNF by midnight, the day is not a covered Part A
day; accordingly, consolidated billing would not apply.
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• 1999 SNF PPS Final Rule: The
preamble to the SNF PPS Final Rule (64 FR 41672-75, July 30, 1999)
clarifies that the scope of coverage under the Part A SNF benefit
includes transportation via ambulance in situations meeting the
general medical necessity requirements (as set forth in 42 CFR 410.40(d)(1))
that would apply to Part B coverage under the separate ambulance services
benefit if the services were not covered under Part A; i.e., those
situations in which a beneficiary’s medical condition is such that
other means of transportation would be contraindicated. In those
situations that do not contraindicate the use of other, non-ambulance modes
of transportation to obtain services from offsite sources, the preamble
indicates that the facility’s fundamental obligation is to ensure
that each resident receives those services needed to attain or maintain
the resident’s “...highest practicable physical, mental, and psychosocial well-being”
in accordance with regulations at 42 CFR 483.25. In fulfilling this
basic obligation, however, an SNF may utilize a wide variety of
means either to send its residents to the offsite location of the
services or, alternatively, to bring the services themselves onsite
to its residents.
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Moreover, in contrast
to ambulance trips (for which a specific Part B benefit exists),
there is no Part B benefit that provides coverage for non-ambulance
forms of transportation. Further, SNFs historically have only rarely,
if ever, directly undertaken to provide non-ambulance forms of transportation
to their residents as part of a covered Part A stay. While in theory,
the pre-PPS procedures for SNF cost reporting and payment under
Part A could have recognized the costs incurred if SNFs had elected
to undertake this function themselves, SNFs were in fact under no
obligation to do so, and in actual practice, the responsibility
for providing such transportation for SNF residents has generally
been assumed instead by other sources, such as the Medicaid program,
local community service organizations, or the resident’s own family.
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In this context,
the preamble to the final rule explains that it is not our intent
to include within the scope of the current SNF PPS bundle any types
of transportation services for which the Medicare program did not
previously assume financial responsibility under either Part A or
Part B. Accordingly, the final rule clarifies that the scope of
the required service bundle furnished to Part A SNF residents under
the PPS specifically encompasses coverage of transportation via
ambulance under the conditions described above, rather than more
general coverage of other forms of transportation.
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