Episode 21 of Reimbursement Readiness: Business Tips for Wound Practice addresses one of the most common—and costly—sources of claim denials in wound care: Medicare consolidated billing. Kathleen Schaum is joined by reimbursement expert Yesenia Banks, who explains why many wound care stakeholders only learn about consolidated billing after claims are denied or payments are recouped.

In this episode, Yesenia breaks down the fundamentals of home health and skilled nursing facility consolidated billing rules, including how payment responsibility is assigned during a defined episode of care and why verifying a patient’s status is critical before billing Medicare. She also walks through key distinctions that affect wound care services—such as what is bundled within the home health PDGM model, what remains separately payable under Medicare Part B, and how negative pressure wound therapy is handled differently depending on the care setting. The discussion also clarifies how consolidated billing functions within the SNF PDPM payment model, including the four CMS billing files used to determine which services are excluded, separately billable, or the responsibility of the facility. The episode closes with practical guidance and CMS resources to help providers avoid denials, compliance risk, and unexpected recoupments.

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Home Health Consolidated Billing list:
https://www.cms.gov/medicare/payment/prospective-payment-systems/home-health/coding-and-billing-information

Skilled Nursing Facility Consolidated Billing List
https://www.cms.gov/medicare/payment/prospective-payment-systems/skilled-nursing-facility-snf/consolidated-billing

There are four Skilled Nursing Facility Consolidated billing list files:

• File #1 - Part A Stay (2026 Physician Services)(Physician Professional Services Other than Interpretation of Diagnostic Tests) These codes are not subject to SNFconsolidated billing.

• File #2 - Part A Stay (2026 Physician)(Professional Component of Services to be Submitted with a 26Modifier) These odes are not subject to SNF consolidated billing.
• File #3 Part A Stay (Ambulance) These codes are not subject to SNF consolidated billing.
• File #4 - Part B Stay Only (Therapy) These therapy codes are subject to SNF consolidated billing and must be billed through the SNF.