Military Health System

•  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.

•  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.

•  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.

•  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:

•  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).

•  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 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.

•  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.