Did you know that improper billing practices account for millions of dollars in Medicare overpayments each year?

“According to the officials, a common audit finding is that Medicare contractors continued to pay separate Part B claims for services that should have been included in consolidated billing, suggesting confusion about which services are included in the bundled payment versus excluded services billable separately.” Office of Inspector General

For SNF residents who often require routine podiatry care due to:

  • Diabetes
  • Circulatory issues
  • Mobility limitations

Understanding these billing rules isn’t about compliance; it’s about ensuring patients’ care. They need to do so without compromising the facility’s financial standing.

When a Medicare beneficiary enters a SNF, a complex set of billing rules applies. These rules can confuse even experienced healthcare administrators. One of the most important, yet often misunderstood, is SNF consolidated billing. Podiatry services face challenges with foot care needs and billing compliance. These issues need careful attention.

This guide explains SNF consolidated billing for podiatry services. It gives valuable tips for podiatrists working with the SNF population. To avoid costly audits and ensure residents receive proper foot care, it’s essential to understand these regulations.

Understanding SNF Consolidated Billing

SNF consolidated billing is a Medicare payment regulation established in 1998 that requires skilled nursing facilities to bill Medicare for virtually all services provided to residents during a covered Part A stay.

What Is SNF Consolidated Billing?

The SNF receives a bundled daily payment rather than having many providers bill Medicare separately. This payment covers most care, supplies, and services provided in the facility.

The main goal of this rule is to simplify Medicare payments. It also aims to prevent duplicate billing and ensure accountability for care in SNF settings. Under this system, the facility arranges and pays for covered services. It then gets reimbursed through Medicare’s payment system. The resident’s resource use group (RUG) classification determines this reimbursement. 

What’s Included in Consolidated Billing?

The scope of consolidated billing is broad and includes:

  • Physical, mental, and speech therapy services
  • Laboratory tests and diagnostic services are performed at the facility
  • Medical supplies and durable medical equipment (with some exceptions)
  • Medications administered during the stay
  • Contracted providers provide most ancillary services
  • Routine nursing care and personal care services

What’s Excluded from Consolidated Billing?

Certain services remain separately billable to Medicare Part B, including:

  • Physician services (evaluation and management visits)
  • Certain high-cost, low-probability services specified by Medicare
  • Ambulance services to outside locations
  • Dialysis services for patients with end-stage renal disease
  • Some chemotherapy and radiation therapy
  • Selected diagnostic services are not available at the facility

Compliance Risks and Audit Concerns

Medicare takes consolidated billing violations seriously. SNFs that fail to comply with these regulations face several risks, including:

  • Recovery of improper payments through audits, 
  • Potential exclusion from Medicare participation in severe cases, 
  • Damage to reputation and relationships with referring providers. 

The Office of Inspector General regularly identifies consolidated billing errors as a target area for recovery audits. Facilities need strong systems to identify services included in their consolidated billing. They must also inform outside providers that they can’t bill Medicare directly for most services provided to SNF residents during a Part A stay.

Podiatry Services in Skilled Nursing Facilities

Residents of skilled nursing facilities commonly require podiatry services due to age-related foot conditions, complications from chronic diseases like diabetes, and mobility limitations that make self-care difficult.

Why We Need Critical Podiatric Care

Foot health directly impacts a resident’s ability to ambulate safely, maintain independence, and avoid serious complications such as infections or amputations.

What are Common Podiatry Services in SNFs

Podiatrists provide a range of services to SNF residents, including:

Routine foot care: 

This includes nail trimming, callus removal, and corn treatment. For residents with diabetes or circulatory issues, these seemingly simple procedures require professional expertise to prevent complications.

Diabetic foot examinations: 

Comprehensive assessments to identify neuropathy, circulation problems, and potential ulceration risks. Early detection can prevent serious complications that lead to hospitalization or amputation.

Treatment of foot conditions: 

Management of ingrown toenails, fungal infections, plantar warts, and other dermatological foot problems that can cause pain and limit mobility.

Wound care: 

Treatment of foot ulcers, pressure sores, and other wounds that require specialized podiatric intervention beyond routine nursing care.

Custom orthotics and footwear: 

Assessment and provision of therapeutic shoes or orthotic devices to address biomechanical issues or accommodate deformities.

How Podiatry Intersects with Consolidated Billing

The complexity arises because Medicare’s rules for podiatry services don’t align neatly with consolidated billing regulations. While SNFs must bill for most services provided to residents during a Part A stay, podiatry has unique billing considerations based on whether the services are considered routine care or treatment of a medical condition.

Medicare Part B covers podiatry services for specific medical conditions affecting the legs, like injuries or diseases. Routine foot care is usually not covered.

If the beneficiary has a condition like diabetes, this care might be needed. This distinction is vital in the SNF setting. The consolidated billing rule requires the facility to cover services that Medicare Part B usually bills.

What Are The Main Challenges of SNF Podiatry Billing

The Confusion Over Billing Authority

One of the most common challenges SNFs face is determining which podiatry services fall under consolidated billing and which can be billed separately. The rules create a gray area that leads to frequent billing errors. 

Many podiatrists who serve SNF residents are accustomed to billing Medicare directly for their services. However, during a covered Part A SNF stay, most podiatry services must be billed by the facility under the consolidated billing requirement, not by the podiatrist.

The exception is when podiatry services are provided by a physician (DPM) and constitute physician services under Medicare Part B, specifically, evaluation and management services. Even then, the line between what constitutes a separately billable physician service versus a consolidated service remains murky.

Compliance Issues

Another common issue arises with diabetic shoe programs. Medicare covers therapeutic shoes and inserts for beneficiaries with diabetes under Part B. However, when these are provided during a Part A SNF stay, questions arise about who should bill and how payment should be handled. The facility may not have systems in place to order and bill for these items, while the podiatrist’s usual suppliers expect to bill Medicare directly.

Solutions for Common Challenges

SNFs can implement several strategies to navigate these challenges:

Clear contractual agreements:

Create written agreements with podiatry providers. These should detail billing, payment, and documentation needs. The contract must state that during Part A stays, the facility will pay the podiatrist directly. It will then bill Medicare using the consolidated payment system.

Staff Education:

Ensure that all staff are aware of the rules for podiatry services. Regular training updates can help avoid accidental violations.

Billing System Flags:

Set up alerts in the electronic health record or system. These alerts should identify residents on Part A stays. They will trigger the proper billing protocols for podiatry and other services.

Regular Compliance Reviews:

Conduct regular audits of podiatry billing. This helps identify and fix errors before they lead to compliance issues. Review SNF claims submitted by contracted podiatrists and ensure there are no duplicate bills.

Practical Tips for SNFs and Podiatrists

SNFs and podiatrists should work together and decide who will manage billing under consolidated rules. They should do this before they provide any services or supplies.

For Skilled Nursing Facilities

Here are some points to be noted:

Ensure that direct lines of communication

Ensure that direct lines of communication are established between your billing office, nurses, and the contracted podiatrists. Each person needs to know who is billing for Part A versus Part B, which determines who gets the bill.

Develop firm policies and procedures:

Write down how a request for podiatry care, recording, billing, and payment occurs. Create simple flow diagrams or decision trees for staff to select the billing option readily.

Evaluate Part A correctly:

Systems must provide clear indicators of which residents participate in a covered Part A stay, Part B, and which are not covered. This information needs to be readily available to anyone who schedules or bills for ancillary services.

Pre-admission planning:

When possible, address projected podiatry needs at the time of admission. When a resident needs specialized foot care, this type of planning is necessary.

Documenting the issue:

Encourage nurses to document all issues related to the feet. This will form a basis for medical necessity in ordering podiatrist services.

For Podiatrists Serving SNFs

Here are some points to be noted:

Be familiar with different environments:

The role you have in different settings varies in SNF settings for Part A stays. In most cases, you can’t bill Medicare for the services you provide to residents.

Negotiate fair payment arrangements:

Base your negotiation of fair payment terms with the SNFs on a reasonable services rate with regard to consolidated billing. Since Medicare billing is not direct billing, the facility must repay you from its daily rate.

Document fully:

Provide complete documentation of your visits that demonstrates medical necessity and the services provided. Good documentation is vital to the hospital because it helps it remain compliant and preserve the bundled payment it receives.

Educate SNF staff:

Most people have little understanding of the foot health issues and the timely need for podiatric treatment. Educate nursing staff on when to request podiatry consultations, as well as how to monitor foot conditions between visits.

Stay current on regulations in Medicare:

Consolidated billing rules and podiatry criteria for coverage are updated periodically. Regularly review Medicare updates and guidance to make sure practices are compliant.

Case Study 1: OIG Audit on Podiatry Routine Foot Care Services (2025)

Key Findings:

  • OIG audited 100 podiatrist claims for routine foot care (RFC) services related to systemic conditions during 2019-2020. Of these, 49 claims (49%) did not comply with Medicare requirements.
  • The audit estimated that of $18.2 million paid by Medicare during the audit period, approximately $4.4 million did not comply with Medicare requirements 
  • Medicare does not generally cover routine foot care services unless the enrollee has systemic medical conditions that increase the risk of infection or injury if a medical professional does not perform the services.
  • This was a follow-up to a 2002 OIG report that found Medicare inappropriately paid podiatrists for RFC services that were medically unnecessary and insufficiently documented.

Why This Matters for SNFs:

This demonstrates the critical importance of proper documentation when podiatry services are provided to SNF residents. Even when services are provided, nearly half failed to meet Medicare’s requirements due to insufficient documentation of medical necessity or systemic conditions.

CASE STUDY 2: The Pamidronate Infusion Billing Denial 

The Case:

Mrs. B, a patient with metastatic breast cancer, entered an oncology office to receive pamidronate as regularly scheduled. She had blood drawn to determine creatinine levels, and a two-hour infusion was administered. The patient was a Medicare beneficiary, and the office submitted the claim for reimbursement through Medicare Part B. Weeks later, the office received a notice from Medicare that all charges on the claim had been denied.

The Problem:

The denial occurred because Mrs. B was a Medicare patient with a covered Medicare Part A stay in a skilled nursing facility at the time of her appointment in the office.

What Went Wrong:

The oncology practice followed its standard billing procedure, not realizing that the patient’s SNF Part A status had changed and who should be billed. Similar scenarios play out in oncology practices across the United States every day, and obtaining reimbursement for services provided to an SNF resident is among the most frequently asked coding and billing-related questions.

The Billing Issue:

Pamidronate (a bisphosphonate used to treat bone complications from cancer) is included in SNF consolidated billing, not excluded. The oncology practice should have billed the SNF directly rather than Medicare Part B.

Financial Impact:

The oncology practice received no payment from Medicare and had to navigate the difficult process of billing the SNF retroactively. Many oncology practices report that reimbursements from SNFs are difficult to obtain. The cost of oncology services increases the total cost of care for an SNF resident beyond the per diem rate the SNF will receive.

Lessons Learned:

The practice should identify patients as SNF residents, ideally at the time the appointment is scheduled. Staff should educate patients and their families about the need to inform staff about the patient’s status when making an appointment, and should encourage local SNFs to note that a patient is a resident when calling for an appointment.

Expert Advice from the Case:

Lisa Gahara, Health Plan Manager and Billing Supervisor at New Hampshire Oncology-Hematology, shared:

 “It’s a good idea to call the SNF to verify that the patient is truly considered an SNF resident and to let it know what services the practice will be providing. This call is a courtesy to the SNF in case it wants to purchase the drug and administer it at the SNF.”

Conclusion

Consolidated billing at an SNF represents a major intersection of patient care, regulatory compliance, and financial management. In the case of podiatry services, understanding these rules is not simply an administrative concern; it directly affects whether residents receive much-needed foot care and whether facilities maintain Medicare compliance.

The key takeaways are realizing that consolidated billing applies to most services during Part A SNF stays, and that includes most podiatry care; maintaining clear contracts and communicating with podiatry providers about who is responsible for billing; having robust systems in place to track resident coverage status to ensure proper billing; and comprehensive documentation to support medical necessity and compliance.

For the administrator and billing staff, investment of time in understanding these regulations and building appropriate systems pays dividends through improved compliance, reduced audit risk, and better coordination of resident care. 

To podiatrists, adapting your practice to accommodate SNF billing requirements opens opportunities to serve a population with significant foot care needs while maintaining regulatory compliance.

The regulatory environment is constantly changing, and this will create the need for continuous education and awareness. Stay up-to-date with CMS updates, industry forums, and training; and communicate openly with your Medicare Administrative Contractor when questions arise about specific billing scenarios.

FAQ’s

What is included in SNF consolidated billing?

The consolidated billing requirement gives SNFs the billing responsibility for the care that residents receive during a covered Part A SNF stay.

What is the full form of SNF?

SNF most commonly stands for Skilled Nursing Facility, a healthcare center for short-term rehabilitation and medical care after hospitalization.

What does Part A cover?

Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care. covers. skilled nursing facility care

What does consolidated billing mean?

Consolidated billing simply describes the method of combining multiple transactions into a single invoice.

What is the purpose of consolidated billing?

The consolidated billing requirement was set forth in statutory language and designed to eliminate duplicate billings for services rendered to SNF patients by multiple providers.