Q&A: Services included in room and board

Q: We have recently been receiving defense audits from commercial payers. There have been several services that they are disallowing, stating that these services should be included in the room and board and fall under routine services. These payers continue to refer to Chapter 22 of CMS’ Provider Reimbursement Manual.

Chapter 22 states that some nursing services are included in the room and board, but what we are finding is that the commercial payers are applying this liberally to include respiratory therapists’ services, PICC and midline insertions, and labs performed on an IStat machine, just to name a few.

I have queried our MAC educator to see if there is something specific out there from CMS, but I am curious to see if other facilities are experiencing the same scenarios with the commercial payors and what your facility has done in response.

A: Check the Provider Reimbursement Manual Part 1 (PRM 1) Chapter 22. CMS also re-published a transmittal stating that these services can be charged separate when PRM 1 instructions are followed—see R2877CP and R3106CP.

Note: This question can be found in the reimbursement and payment methodologies section on the NAHRI Forums where you can find answers to questions on a variety of topics from billing and claims to compliance to reimbursement. This question was answered by Valerie Rinkle, MPA, lead regulatory specialist and instructor for HCPro in Middleton, Massachusetts.