• 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 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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