Medicare Claims Processing Manual 
Chapter 7 - SNF Part B Billing (Including Inpatient Part B and  
Outpatient Fee Schedule) 
Table of Contents                                                                                                                      
(Rev. 10880, 08-06-21) 
 
Transmittals for Chapter 7 
10 - Billing for Medical and Other Health Services 
10.1 - Billing for Inpatient SNF Services Paid Under Part B 
10.1.1  Editing of Skilled Nursing Facilities Part B Inpatient Services 
10.2  Billing for Outpatient SNF Services 
10.3 - Determining How Much to Charge Before Billing Is Submitted 
10.4 - Charges for Services Provided in Different Accounting Years 
10.5 - General Payment Rules and Application of Part B Deductible and 
Coinsurance 
20 - Use of Healthcare Common Procedure Coding System (HCPCS) 
30 - Billing Formats 
30.1 - Frequency of Billing for Skilled Nursing Facilities (SNFs) 
30.2 - Guidelines for Submitting Corrected Bills 
40 - Billing Part B Rehabilitation Services 
40.1 - Audiologic Tests 
50 - Billing Part B Radiology Services and Other Diagnostic Procedures 
50.1 - Bone Mass Measurements 
60 - Billing for Durable Medial Equipment (DME), Orthotic/Prosthetic Devices, and 
Supplies (including Surgical Dressings) 
60.1 - Billing 
60.2 - Determining Payment and Patient Liability 
60.3 - Billing for Enteral and Parenteral Nutritional Therapy as a Prosthetic 
Device 
70 - Drugs 
70.1 - Immunosuppressive Drugs Furnished to Transplant Patients 
80 - Screening and Preventive Services 
80.1 - Pneumococcal Pneumonia, Influenza Virus, and Hepatitis B Vaccines  80.2 - Mammography Screening 
80.2.1 - Diagnostic and Screening Mammograms Performed With New 
Technologies 
80.3 - Screening Pap Smears 
80.4 - Screening Pelvic Examinations 
80.5 - Prostate Cancer Screening 
80.6 - Colorectal Cancer Screening 
80.7 - Glaucoma Screening 
90 - Billing for Laboratory Tests Under Part B - General 
90.1 - Glucose Monitoring 
100 - Epoetin (EPO) 
110 - Carrier Claims Processing for Consolidated Billing for Physician and Non-
Physician Practitioner Services Rendered to Beneficiaries in a Non-covered SNF Stay 
    10 - Billing for Medical and Other Health Services                               
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21) 
 
See Business Requirements at https://www.cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/Downloads/R20CP.pdf. 
 
There are three situations in which a SNF may submit a claim for Part B services.  These 
are identified in subsections A through C below. 
 
No bill is required when: 
 
  The patient is not enrolled under Part B; 
 
  Payment was made or will be made by the Public Health Service, VA, or other 
governmental entity; 
 
  Workers' compensation has paid or will pay the bill; or 
 
  Payment was made by liability, no-fault insurance, group health plan, or a large 
group health plan. 
 
A - Beneficiaries in a Part B Inpatient Stay (Part B Residents) 
 
A Part B inpatient stay includes services furnished to inpatients whose benefit days are 
exhausted, or who are not entitled to have payment made for services under Part A.  A 
more detailed description of services covered for beneficiaries in a Part B stay is found at 
10.1  Billing for Inpatient Services Paid Under Part B. 
 
B - Outpatient Services 
 
Covered Part B services rendered to beneficiaries who are not inpatients of a SNF are 
considered SNF outpatient services.  They include the services listed in 10.1 below as 
well as additional services described in the Medicare Benefit Policy Manual, Chapter 8, 
"Coverage of Extended Care (SNF) Services Under Hospital Insurance," 80 and 
Medicare Benefit Policy Manual, Chapter 6, "Hospital Services Covered Under Part B."  
Detailed instructions for billing are located in 10.2  Billing for Outpatient SNF 
Services. 
 
C - Beneficiaries in a Part A Covered Stay 
 
SNFs are required to consolidate billing to their intermediary for their covered Medicare 
inpatient services.  However, certain services rendered to SNF inpatients are excluded 
from the SNF Prospective Payment System (PPS) reimbursement and are also excluded 
from consolidated billing by the SNF.  Those services must be billed to Part B by the 
rendering provider and not by the SNF (except screening and preventive services as 
described in the next paragraph.)  A list of services excluded from consolidated billing is  found in the Medicare Claims Processing Manual, Chapter 6, "SNF Inpatient Part A 
Billing," 20  20.4. 
 
Screening and preventive services are not included in the SNF PPS amount but may be 
paid separately under Part B for Part A patients who also have Part B coverage.  
Screening and preventive services are covered only under Part B.  Only the SNF may bill 
for screening and preventive services under Part B for its covered Part A inpatients.  Bill 
type 22X is used in billing screening and preventive services for beneficiaries in a 
covered Part A stay and for beneficiaries that are Part B residents.  TOB 23x is used for 
SNF outpatients or for beneficiaries not in the SNF or DPU.  The SNF must provide the 
service or obtain it under arrangements. 
 
Coverage, billing and payment guidelines are found in the Medicare Claims Processing 
Manual, Chapter 18, "Preventive and Screening Services;" Chapter 17, "Drugs and 
Biologicals;" and the Medicare Benefit Policy Manual, Chapter 15, "Covered Medical 
and Other Health Services," 50.4.4.2. 
 
There are certain medical and other health services for which payment may not be made 
to a SNF.  Most of these are professional services performed by physicians and other 
practitioners.  These services are always billed to the Medicare Part B MAC.  Others are 
services that have been determined to require a hospital setting to assure beneficiary 
safety.  Part A MAC shared systems receive an annual file listing these non-payable 
HCPCS in November, and, if necessary, a quarterly update via a one-time-only 
notification. 
 
Physicians, non-physician practitioners, and suppliers billing the Part B MAC, and 
providers billing the Part A MAC should consult the CMS Web site at 
http://www.cms.hhs.gov/SNFConsolidatedBilling/ for lists of separately billable services. 
    10.1 - Billing for Inpatient SNF Services Paid Under Part B 
(Rev. 980, Issued: 06-14-06, Effective: 10-01-06, Implementation: 10-02-06) 
 
When the beneficiary in a Medicare-certified SNF is not entitled to Part A benefits, 
limited benefits are provided under Part B.  Reasons for not being entitled to have 
payment made under Part A are that: 
 
  The beneficiary does not have Medicare Part A Health Insurance; 
 
  The beneficiary is not in a Medicare-certified bed; 
 
  The inpatient stay is not at a covered level of care and no Part A program payment 
is possible; or 
 
  The inpatient stay is not covered because the beneficiary did not have a 3-day 
qualifying stay. 
 
When no Part A program payment is possible, some or all services may be medically 
necessary and can be covered as ancillary services under Part B.  The following services 
may be billed by the SNF or the rendering provider or supplier under an arrangement 
with the SNF: 
 
  Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests; 
  X-ray, radium, and radioactive isotope therapy, including materials and 
services of technicians; 
  Surgical dressings, and splints, casts, and other devices used for reduction of 
fractures and dislocations; 
  Prosthetic devices (other than dental) which replace all or part of an internal 
body organ (including contiguous tissue), or all or part of the function of a 
permanently inoperative or malfunctioning internal body organ, including 
replacement or repairs of such devices; 
  Leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes 
including adjustments, repairs, and replacements required because of 
breakage, wear, loss, or a change in the patients physical condition; 
  Outpatient physical therapy, outpatient speech-language pathology services, 
and outpatient occupational therapy (see Pub. 100-02 Medicare Benefit Policy 
Manual, chapter 15, Covered Medical and Other Health Services, 220 and 
230. 
  Screening mammography services; 
  Screening pap smears; 
  Influenza, pneumococcal pneumonia, and hepatitis B vaccines; 
  Colorectal screening; 
  Bone mass measurements;    Diabetes self-management; 
  Prostate screening; 
  Ambulance services; 
  Hemophilia clotting factors for hemophilia patients competent to use these 
factors without supervision); 
  Immunosuppressive drugs; 
  Oral anti-cancer drugs; 
  Oral drug prescribed for use as an acute anti-emetic used as part of an anti-
cancer chemotherapeutic regimen; and 
  Epoetin Alfa (EPO). 
 
See chapter 6 of Pub. 100-02, Medicare Benefit Policy Manual for a discussion of the 
circumstances under which the above services may be covered as Part B Inpatient 
services. 
 
Coverage rules for these services are described in Pub. 100-02, Medicare Benefit Policy 
Manual, Chapters 10, 14, or 15.  Specific billing instructions are found in the Medicare 
Claims Processing Manual, Chapters 13, 15, 16, 18, 20, or 23. 
 
Outpatient physical therapy, outpatient speech-language pathology services, and 
outpatient occupational therapy (see Chapter 10, 60) are billable services for SNF 
inpatients not in a Part A stay.  However, they must be billed by the SNF even when 
another entity renders the services under an arrangement with the SNF. 
 
The determination of whether to use TOB 22x or 23x is a function of the type of facility 
in which the beneficiary resides.  If the facility is not Medicare-certified, it is not a SNF, 
although it may have a Medicare-certified distinct part unit (DPU).  If the beneficiary is 
in a SNF or SNF DPU, Part B services must be billed on TOB 22x. 
 
All services rendered to SNF patients residing in the non-Medicare-certified portion of an 
institution that is not primarily engaged in the provision of skilled services must be billed 
on TOB 23x.  Beneficiaries residing in such portions of the facility are considered 
outpatients of the SNF for Medicare purposes. 
 
If the entire facility qualifies as a Medic are-certified SNF, all Part B services rendered to 
residents are billed on TOB 22x. 
 
10.1.1 - Editing of Skilled Nursing Facilities Part B Inpatient Services 
(Rev. 3481, Issued: 03-18-16. Effective: 06-20-16, Implementation: 06-20-16) 
 
Medicare pays under Part B for physicians services and for non-physician medical and 
other health services listed below when furnished by a participating hospital to an 
inpatient of the SNF when patients are not eligible or entitled to Part A benefits or the 
patient has exhausted their Part A benefits.   
The SSM shall edit to prevent payment on Type of Bill 22x for claims containing the 
revenue codes listed in the table below. 
 
010x  011x  012x  013x  014x  015x  016x  017x 
018x  019x  020x  021x  022x  023x  024x  0250 
0251  0252  0253  0256  0257  0258  0259  0261 
0269  0270  0273  0277  0279  029x  0339  036x 
0370  0374  041x  045x  0472  0479  049x  050x 
051x  052x  053x  0541  0542  0543  0544  0546 
0547  0548  0549  055x  057x  058x  059x  060x 
0630  0631  0632  0633  0637  064x  065x  066x 
067x  068x  072x  0762  078x  079x  093x  0940 
0941  0943  0944  0945  0946  0947  0949  095x 
0960  0961  0962  0969  097x  098x  099x  100x 
210x  310x           
 
The contractor shall use the following remittance advice messages and associated codes 
when rejecting/denying claims under this policy.  This CARC/RARC combination is 
compliant with CAQH CORE Business Scenario Three. 
 
Group Code: CO  
CARC: 96  
RARC: M28 
MSN: 21.21 
 
10.2  Billing for Outpatient SNF Services 
(Rev. 229, Issued 07-20-04 Effective/Implementation 08-19-04) 
SNF-529 
 
Coverage is available for all of the services described in 10.1.  However, beneficiaries 
not in the Medicare-certified Distinct Part Unit (DPU) are not required to have therapy 
services (physical therapy, occupational therapy, and speech language pathology) billed 
by the SNF.  Therapy services need only be bundled to the SNF for those SNF residents 
in a Medicare-certified DPU.  For additional information see Chapter 6, SNF Inpatient 
Part A Billing, 20.5 Therapy Services. 
 
10.3 - Determining How Much to Charge Before Billing Is Submitted 
(Rev. 1, 10-01-03) 
SNF-529.1 
 
The SNF may be able to determine from the SNF's records, from a transferring hospital, 
or from the patient the extent to which the Part B cash deductible is met.  The SNF may 
charge the patient for the unmet deductible and coinsurance.  The SNF should submit a 
bill even if no payment can be made because the unmet Part B cash deductible exceeds  the covered charges.  In addition, a bill is required when the SNF becomes aware that no 
bill has been submitted for covered services even though the time limitation for filing has 
expired. 
 
10.4 - Charges for Services Provided in Different Accounting Years 
(Rev. 1, 10-01-03) 
SNF-529.2 
 
The SNF must not put charges for services provided in different accounting years on the 
same bill.  At the end of the SNF's accounting year, the SNF should submit a bill that 
contains the charges for all services furnished to the patient since the last bill through the 
end of the year.  The SNF should include bills in which the deductible covers all charges.  
All services furnished in the succeeding accounting year should be placed on a separate 
bill.  Complete all items on the subsequent bill. 
 
10.5 - General Payment Rules and Application of Part B Deductible and 
Coinsurance 
(Rev. 685, Issued: 09-23-05, Effective: 12-27-05, Implementation: 12-27-05) 
SNF-529.3 
 
Section 1888(e)(9) of the Social Security Act (the Act) requires that the payment amount 
for Part B SNF services shall be the amount prescribed in the otherwise applicable fee 
schedule.  Thus, where a fee schedule exists for the type of service, the fee amount will 
be paid.  Where a fee does not exist on the Medicare Physician Fee Schedule (MPFS) the 
particular service is priced based on cost.  This is also true for all carrier-priced codes 
on the MPFS, but not for services paid on the Clinical Diagnostic Laboratory Fee 
Schedule.  All lab services missing fees are to be gap-filled.  Some specific services 
continue to be paid on a cost basis and are specifically stated in the sections below where 
cost applies. 
 
Where payment is made under a fee schedule, the beneficiary's deductible and 
coinsurance are based on the approved amount.  Where payment is made on a cost basis, 
deductible and coinsurance are based on charges for the service. 
 
20 - Use of Healthcare Common Procedure Coding System (HCPCS) 
(Rev. 1, 10-01-03) 
SNF-530, SNF-530.3 
 
HCPCS is required for reporting all SNF services paid under Part B, whether paid by 
Medicare fee schedules or by some other mechanism.  A description of HCPCS codes is 
found in the Medicare Claims Processing Manual, Chapter 23. 
 
The SNF should use the CPT-4 portion of HCPCS and/or Level II as directed by the 
manual sections applicable to the Part B service that is being billed.  Currently, HCPCS 
codes are not applicable on SNF Part A inpatient claims. 
  For Part B claims, there are separate codes for the technical component, professional 
component, and/or complete procedure.  Generally, SNFs bill for the technical 
component only, using the code that describes the procedure provided. 
 
There may be specific rules for use of HCPCS codes for specific types of services (e.g., 
SNF's must bill global services for therapies).  These will be described in the manual 
sections for the applicable service. 
 
Revenue codes, HCPCS codes, line item dates of service, and units are required.  Charges 
must be reported by HCPCS code.  If the same revenue code applies to two or more 
HCPCS codes, the SNF should repeat the revenue code and show the line item date of 
service, units and charge for each HCPCS code on a separate line. 
 
30 - Billing Formats 
(Rev. 3053, Issued: 08-28-14, Effective: ICD-10: Upon Implementation of ICD-10 
ASC-X12: 01-01-12, Implementation ICD-10: Upon Implementation of ICD-10; 
ASC X12: 09-30-14) 
 
The SNF must use the current ASC X12 837 institutional claim format or if permissible 
Form CMS-1450 to bill for covered Part B services.  Instructions for those formats are 
located in the Medicare Claims Processing Manual, Chapter 25, "Completing and 
Processing the CMS-1450 Data Set." 
 
30.1 - Frequency of Billing for Skilled Nursing Facilities (SNFs) 
(Rev. 1, 10-01-03) 
SNF-561 
 
SNFs must bill repetitive Part B services on a single individual monthly bill (or at the 
conclusion of treatment).  This avoids Medicare processing costs in holding such bills for 
monthly review and reduces bill processing costs for relatively small claims.  See the 
Medicare Claims Processing Manual, Chapter 1, "General Billing Requirements," 
50.2.2, for additional instructions when billing repetitive services and billing repetitive 
services during an inpatient stay. 
 
Other one-time Part B services must be billed upon completion of the services. 
 
30.2 - Guidelines for Submitting Corrected Bills 
(Rev. 1, 10-01-03) 
SNF-562, SNF-562.A 
 
When a SNF or intermediary discovers an error on an original bill, there are three 
methods for correcting the bill depending on the type of error.  The SNF or intermediary 
may submit a late charge bill, an adjustment request, or maintain a log of charges.  Each 
of the methods and appropriate use are explained in the Medicare Claims Processing 
Manual, Chapter 1, "General Billing Requirements," 130. 
  40 - Billing Part B Rehabilitation Services 
(Rev. 1, 10-01-03) 
SNF-515.6 
 
Part B rehabilitation services other than audiology services must be billed by the SNF for 
Part A inpatients, for Part B residents (those not in a covered Part A stay) and for 
outpatients.  Effective January 1, 1999, the MPFS is the payment basis for these services. 
 
The Medicare Claims Processing Manual, Chapter 5, "Part B Outpatient Rehabilitation 
and CORF Services," contains instructions for billing, payment, and applicable HCPCS 
codes. 
 
40.1 - Audiologic Tests 
(Rev. 980, Issued: 06-14-06, Effective: 10-01-06, Implementation: 10-02-06) 
 
Audiologic tests will generally be billed to the carrier by the provider of service.  For 
tests that include both a professional component and technical component, the SNF may 
elect to bill the technical component to the intermediary, but is not required to bill the 
service.  See Pub 100-02 chapter 15, section 80.3 for further information on audiology. 
 
Payment to SNFs for audiologic tests are bundled into the PPS payment amount for 
beneficiaries in a covered SNF Part A stay, whether provided directly by the SNF or 
under arrangements by an independent provider based on a contract with the SNF.  
Independent audiologists may bill the carrier directly for services rendered to 
beneficiaries not in a SNF Part A covered stay.  For beneficiaries not in a covered Part A 
SNF stay, who are sometimes referred to as beneficiaries in a Part B SNF stay, audiologic 
tests are payable under Part B when billed by the SNF as type of bill 22X, or when billed 
directly to the carrier by the provider of the service.  Payment is based on the Medicare 
Physician Fee Schedule (MPFS), whether by the carrier or the intermediary. 
 
Since audiologic tests are not bundled with speech -language pathology services, 
payment is made to the provider of service or to the SNF where the services are provided 
under arrangements with the SNF for SNF outpatients. 
 
50 - Billing Part B Radiology Services and Other Diagnostic Procedures 
(Rev. 1, 10-01-03) 
 
Acceptable HCPCS codes for radiology and other diagnostic services are taken primarily 
from the CPT-4 portion of HCPCS.  Payment is the lower of billed charges or the fee 
schedule amount.  In either case, any applicable deductible and coinsurance amounts are 
subtracted from the payment amount prior to payment.  Coinsurance is calculated on the 
Medicare payment amount after the subtraction of any applicable deductible amount. 
 
Additional instructions for coverage, billing, payment, and specific instructions for the 
services listed below are found in the Medicare Claims Processing Manual, Chapter 13, 
"Radiology Services":   
  Contrast material other than low osmolar contrast material (LOCM) for radiology; 
  LOCM; 
  Radiopharmaceuticals; 
  IV Persantine; 
  Transportation of equipment; 
  Position Emission Tomography (PET); and 
  Adenosine. 
 
50.1 - Bone Mass Measurements 
(Rev. 1, 10-01-03) 
SNF-535.5 
 
Sections 1861(s)(15) and 1861(rr)(1) of the Act (as added by 4106 of the Balanced 
Budget Act (BBA) of 1997) standardized Medicare coverage of medically necessary 
bone mass measurements by providing for uniform coverage under Medicare Part B.  
This standardized coverage is effective for claims with dates of service furnished on or 
after July 1, 1998.  The Medicare Claims Processing Manual, Chapter 13, "Radiology 
Services," contains coverage, billing, and payment requirements for bone mass 
measurements. 
 
60 - Billing for Durable Medial Equipment (DME), Orthotic/Prosthetic 
Devices, and Supplies (including Surgical Dressings) 
(Rev. 3053, Issued: 08-28-14, Effective: ICD-10: Upon Implementation of ICD-10 
ASC-X12: 01-01-12, Implementation ICD-10: Upon Implementation of ICD-10; 
ASC X12: 09-30-14) 
 
A SNF may not bill for DME furnished to its Part A inpatients as necessary DME must 
be supplied to the beneficiary as part of SNF services.  A SNF may not bill for DME 
furnished to its Part B inpatients or outpatients.  However, a SNF may qualify as a 
supplier and enroll with the National Supplier Clearinghouse.  In such cases, the SNF is 
given a separate supplier number to bill outpatient DME to the DME MAC.  The DME 
MAC will furnish billing guidelines and payment will be made directly to the SNF as a 
supplier. 
 
The SNF or other entity that furnishes prosthetic and/or orthotic devices to SNF residents 
for whom Part A benefits are not payable (no Part A entitlement or benefits exhausted) 
and for SNF outpatients may bill for such items.  The SNF bills the A/B MAC (A).  
Suppliers bill the A/C MAC (B) or DME MAC.  See Chapter 20 for DMEPOS billing 
requirements, including definition of "supplier." 
 
Prosthetic and orthotic devices are: 
    Prosthetic devices (other than dental) that replace all or part of an internal body 
organ (including connective tissue) or replace all or part of the function of a 
permanently inoperative or malfunctioning internal body organ, including 
replacement or repair of such devices (see the Medicare Benefit Policy Manual, 
Chapter 15, "Covered Medical and Other Health Service," 120); and 
 
  Leg, arm, and neck braces, trusses, and artificial legs, arms, and eyes, including 
adjustments, repairs, and replacement required because of breakage, wear, loss, or 
a change in the patient's physical condition (see the Medicare Benefit Policy 
Manual, Chapter 15, "Covered Medical and Other Health Service," 130). 
 
SNFs bill supplies to its A/B MAC (A) for outpatients. 
 
60.1 - Billing 
(Rev. 3053, Issued: 08-28-14, Effective: ICD-10: Upon Implementation of ICD-10 
ASC-X12: 01-01-12, Implementation ICD-10: Upon Implementation of ICD-10; 
ASC X12: 09-30-14) 
 
The SNF must bill the A/B MAC (A) for prosthetic/orthotic devices, supplies and 
surgical dressings using the ASC X12 837 institutional claim format or if permissible 
Form CMS-1450.  Requirements for billing can be found in the Medicare Claims 
Processing Manual, Chapter 25, "Completing and Processing the CMS 1450 Data Set." 
 
The SNF must bill prosthetic and orthotic devices under revenue code 274, along with the 
appropriate HCPCS code.  When billing for maintenance and servicing of these items, 
revenue code 274 along with the appropriate HCPCS code must be used. 
 
The SNF should report "Units of Service" on Form CMS-1450 the number of items billed 
to the SNF's A/B MAC (A) for orthotics and prosthetics. 
 
Supplies may be billed for SNF outpatients under revenue code 270.  Payment is made 
based on a fee schedule. 
 
The SNF should bill the A/B MAC (A) for surgical dressings under revenue code 623.  
HCPCS codes for reporting surgical dressing are normally found in the Level II HCPCS 
codes in the A6000 series.  The A/B MAC (A) makes payment based on the surgical 
dressing fee schedule. 
 
SNFs use 22X type of bill for orthotic and prosthetic devices and surgical dressings when 
billing for its Part B inpatients.  Orthotic and prosthetic devices, surgical dressings, and 
supplies for outpatients are billed with 23X type of bill. 
 
(See the Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other 
Health Service," 100 for coverage data.) 
 
60.2 - Determining Payment and Patient Liability  (Rev. 1, 10-01-03) 
SNF-534.D, SNF-534.E 
 
There may be prosthetic and orthotic devices, for which the SNF would bill that are not 
included in the fee schedule.  When fee schedule amounts are not available for a 
particular item, the intermediary will pay based on cost. 
 
To determine the SNF's Part B payment, the SNF subtracts any unmet Part B deductible 
from the lower of the actual charge or the fee schedule amount for the item or service and 
multiply the remainder by 80 percent.  This is the final payment.  The patient's liability is 
the remaining 20 percent plus any deductible remaining to be met. 
 
60.3 - Billing for Enteral and Parenteral Nutritional Therapy as a 
Prosthetic Device 
(Rev. 1, 10-01-03) 
(Rev. 3053, Issued: 08-28-14, Effective: ICD-10: Upon Implementation of ICD-10 
ASC-X12: 01-01-12, Implementation ICD-10: Upon Implementation of ICD-10; 
ASC X12: 09-30-14) 
 
Parenteral nutritional (PEN) therapies including the necessary equipment, medical 
supplies and nutrients provided to an inpatient (where Part A payment cannot be made), 
or to individuals who are not inpatients are covered as a prosthesis under the Part B 
prosthetic device benefit as long as the requirements in the Coverage Manual are met, 
and the required documentation is submitted. 
 
The SNF or the supplier must bill the DME MAC.  The SNF or supplier should refer to 
the most recent HCPCS directory or billing instructions distributed by the DME MAC for 
current HCPCS coding information.  If the SNF bills the DME MAC., it must obtain a 
supplier number from the National Supplier Clearinghouse and must use the ASC X12 
837 professional claim format, or if permissible Form CMS-1500. 
 
Billing Instructions are in the Medicare Claims Processing Manual, Chapter 26, 
"Completing and Processing the Form CMS-1500 Data Set."  
 
DME MAC jurisdictions are based on the residence of the beneficiary.  The DME MAC 
for each State is shown on the CMS Web site at 
http://www.cms.hhs.gov/medicare/medicare-contracting/medicare-administrative-
contractors/medicareadministrativecontractors.html . 
 
70 - Drugs 
(Rev. 1, 10-01-03) 
SNF-536, SNF 536.1 
 
Drugs and biologicals furnished to outpatients for therapeutic purposes that are self-
administered are not covered by Medicare unless those drugs and biologicals must be put  directly into an item of durable medical equipment or a prosthetic device.  Exceptions to 
this rule are: 
 
  Self administered drugs administered in an emergency situation; 
 
  Self-administered oral versions of covered injectable cancer drugs prescribed as 
an anti-cancer chemotherapeutic; 
 
  Self-administered anti-emetic drugs; 
 
  Oral anti-emetic drugs as full therapeutic replacements for intravenous dosage 
forms as part of a chemotherapeutic regimen provided that the drug(s) be 
administered or prescribed by a physician for use immediately before, at, or 
within 48 hours after the time of administration of the chemotherapeutic agent; 
and 
 
  Immunosuppressive drugs furnished to transplant patients. 
 
See the Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other 
Health Services," 50 for coverage of drugs. 
 
See the Medicare Claim Processing Manual, Chapter 17, "Drugs," 80 for billing and 
payment instructions. 
 
Where covered under Part B, self administered drugs for SNF inpatients not entitled to 
Part A benefits should be billed using type of bill 22X, and for SNF outpatients, using 
type of bill 23X. 
 
70.1 - Immunosuppressive Drugs Furnished to Transplant Patients 
(Rev. 1, 10-01-03) 
 
Part B of Medicare covers FDA-approved immunosuppressive drugs.  Payment is made 
for those immunosuppressive drugs that have been specifically labeled as such and 
approved for marketing by the FDA, as well as those prescription drugs, such as 
prednisone, that are used in conjunction with immunosuppressive drugs as part of a 
therapeutic regimen reflected in FDA-approved labeling for immunosuppressive drugs.  
Therefore, antibiotics, hypertensives, and other drugs that are not directly related to 
rejection are not covered. 
 
Deductible and coinsurance apply.  SNFs bill using TOB 22X for Part B residents and 
TOB 23x for outpatients. 
 
See the Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other 
Health Services," 50 for coverage of drugs. 
  See the Medicare Claim Processing Manual, Chapter 17, "Drugs," 80 for billing and 
payment instructions. 
 
80 - Screening and Preventive Services 
(Rev. 1, 10-01-03) 
 
Screening and preventive services are only covered as a Medicare Part B benefit.  When 
furnished to a beneficiary in a SNF Part A covered stay, the SNF must bill its 
intermediary using 22X type of bill.  These services are billed on TOB 23x for SNF 
outpatients and beneficiaries outside the Medicare-certified SNF or DPU. 
 
See 10.C for billing preventive services for covered SNF Part A inpatients. 
 
A SNF may bill screening and preventive services for its Part B residents using 22X type 
of bill or the supplier may bill its carrier.  Screening and preventive services rendered to 
SNF outpatients may be billed with 23X type of bill or the supplier may bill its carrier. 
 
HCPCS codes are required.  See the Medicare Claims Processing Manual, Chapter 18, 
"Preventive and Screening Services" for coverage, billing, appropriate HCPCS codes, 
and payment requirements. 
 
Payment is made under the Medicare Physician's Fee Schedule (MPFS) or clinical 
diagnostic lab fee schedule depending on the service. 
 
80.1 - Pneumococcal Pneumonia, Influenza Virus, and Hepatitis B 
Vaccines 
(Rev. 1, 10-01-03) 
SNF-536.2 
 
Part B of Medicare pays 100 percent for pneumococcal pneumonia vaccines (PPV) and 
influenza virus vaccines and their administration.  Payment is made on a cost basis.  
Deductible and coinsurance do not apply.  Part B of Medicare also covers the hepatitis B 
vaccine and its administration.  Deductible and coinsurance apply. 
 
Medicare Claims Processing Manual, Chapter 18, "Preventive and Screening Services," 
contains instructions for simplified billing of Influenza virus vaccine and Pneumococcal 
Pneumonia vaccine by mass immunizers. 
 
80.2 - Mammography Screening 
(Rev. 3053, Issued: 08-28-14, Effective: ICD-10: Upon Implementation of ICD-10 
ASC-X12: 01-01-12, Implementation ICD-10: Upon Implementation of ICD-10; 
ASC X12: 09-30-14) 
 
Section 4163 of the Omnibus Budget Reconciliation Act of 1990 added 1834(c) of the 
Act to provide for Part B coverage of mammography screening for certain women 
entitled to Medicare for screenings performed on or after January 1, 1991.  The term  "screening mammography" means a radiologic procedure provided to an asymptomatic 
woman for the purpose of early detection of breast cancer and includes a physician's 
interpretation of the results of the procedure.  Unlike diagnostic mammographies, there 
do not need to be signs, symptoms, or history of breast disease in order for the exam to be 
covered. 
 
The technical component portion of the screening mammography should be billed on the 
ASC X12 837 institutional claim format or if permissible Form CMS-1450 under bill 
type 22X for SNF Part A and Part B inpatients or 23X for SNF outpatients.  Claims for 
mammography screening should include only the charges for the screening 
mammography. 
 
80.2.1 - Diagnostic and Screening Mammograms Performed With New 
Technologies 
(Rev. 1, 10-01-03) 
 
Section 104 of the Benefits Improvement and Protection Act 2000, (BIPA) entitled 
"Modernization of Screening Mammography Benefit," provides for new payment 
methodologies for both diagnostic and screening mammograms that utilize advanced new 
technologies for the period April 1, 2001, through December 31, 2001.  See the Medicare 
Claims Processing Manual, Chapter 18, "Preventive and Screening Services," for the 
payment method for this period, applicable HCPCS codes, and other billing and 
processing instructions. 
 
Effective January 1, 2002, payment is based on the mammography benefit pricing file 
furnished by CMS. 
 
80.3 - Screening Pap Smears 
(Rev. 1, 10-01-03) 
SNF-541.2 
 
Sections 1861(s)(14) and 1861(nn) of the Act, (as enacted by 6115 of the Omnibus 
Budget Reconciliation Act of 1989) provides for coverage of screening pap smears for 
services provided on or after July 1, 1990.  Screening pap smears are laboratory tests 
consisting of a routine exfoliative cytology test (Papanicolaou test) provided for the 
purpose of early detection of cervical cancer.  It includes a collection of the sample of 
cells and a physician's interpretation of the test. 
 
Payment is made under the clinical diagnostic laboratory fee schedule. 
 
80.4 - Screening Pelvic Examinations 
(Rev. 1, 10-01-03) 
 
Section 4102 of the BBA of 1997 (P.L.  105-33) amended 1861(nn) of the Act (42 USC 
1395X(nn)) to include coverage of screening pelvic examinations for all female 
beneficiaries for services provided January 1, 1998, and later.  Effective July 1, 2001, the  Consolidated Appropriations Act of 2001 (P.L.  106-554) modifies 1861(nn) to provide 
Medicare coverage for biennial screening pelvic examinations. 
 
Payment is made under the Medicare Physician's Fee Schedule (MPFS). 
 
80.5 - Prostate Cancer Screening 
(Rev. 1, 10-01-03) 
 
Sections 1861(s)(2)(P) and 1861(oo) of the Act (as added by 4103 of the Balanced 
Budget Act of 1997), provide for coverage of certain prostate cancer screening tests 
subject to certain coverage, frequency, and payment limitations.  Effective for services 
furnished on or after January 1, 2000, Medicare covers prostate cancer screening 
tests/procedures for the early detection of prostate cancer.  Coverage of prostate cancer 
screening tests includes the following procedures furnished to an individual for the early 
detection of prostate cancer: 
 
  Screening digital rectal examination; and 
  Screening prostate specific antigen (PSA) blood test 
 
Each test may be paid at a frequency of once every 12 months for men who have attained 
age 50 (i.e., starting at least one day after they have attained age 50), if at least 11 months 
have passed following the month in which the last Medicare-covered screening digital 
rectal examination was performed (for digital rectal exams) or PSA test was performed 
(for PSA tests). 
 
Payment is made under the clinical diagnostic laboratory fee schedule. 
 
80.6 - Colorectal Cancer Screening 
(Rev. 1, 10-01-03) 
 
See the Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other 
Health Services," 80.5, for coverage of colorectal rectal screening services. 
 
Effective for services furnished on or after January 1, 1998, payment may be made for 
colorectal cancer screening for the early detection of cancer.  For screening colonoscopy 
services (one of the types of services included in this benefit) prior to July 2001, coverage 
was limited to high-risk individuals.  For services July 1, 2001, and later, screening 
colonoscopies are covered for individuals not at high risk.  Screening colonoscopies are 
not payable to the SNF.  Screening colonoscopies are only covered when rendered in a 
hospital or CAH. 
 
For all other colorectal screening services payment is made under the MPFS or the 
clinical diagnostic laboratory fee schedule based on the service rendered. 
 
80.7 - Glaucoma Screening 
(Rev. 1, 10-01-03)   
The Benefits Improvement and Protection Act of 2000, 102, provides annual coverage 
for glaucoma screening for Medicare beneficiaries with diabetes mellitus, or a family 
history of glaucoma, or African-Americans age 50 and over.  Conditions of coverage for 
glaucoma screening are located in the Medicare Benefit Policy Manual, Chapter 15, 
"Covered Medical and Other Health Services." 
 
Payment is made under the Medicare Physician's Fee Schedule (MPFS). 
 
90 - Billing for Laboratory Tests Under Part B - General 
(Rev. 1, 10-01-03) 
 
Section 1833(h)(5) of the Act (as enacted by The Deficit Reduction Act of 1984, Public 
Law 98-369) requires the establishment of a fee schedule for clinical diagnostic 
laboratory tests paid under Part B. 
 
Section 1833g(5)(A)iii of Title XVIII provides that "in the case of a clinical diagnostic 
laboratory test provided under an arrangement (as defined in 1861(w)(1)) made by a 
hospital, critical access hospital or skilled nursing facility, payment shall be made to the 
hospital or skilled nursing facility." 
 
SNFs must make arrangements under Part A and may make arrangements under Part B 
under which the SNF bills the intermediary and receives payment.  Under this process, 
the SNF pays the lab for services whatever amount the SNF and the lab agree on, and the 
beneficiary may not be charged by the lab. 
 
Where the SNF and a lab have entered into such an arrangement, the arrangement may 
include Part A only or may include Part A and Part B.  Such an arrangement is voluntary 
on the part of both the lab and the SNF for Part B services. 
 
In the absence of such an arrangement under Part B, the lab may bill the program for lab 
services furnished to residents for whom Part A cannot be paid, and for SNF outpatients, 
and the SNF may not bill the program for these services.  Hospital labs and labs in other 
SNFs would bill the intermediary.  Independent labs would bill the carrier. 
 
Laboratory tests performed for the SNF's Medicare inpatients covered under Part A are 
included in the PPS SNF payment. 
 
If the FI receives fee amounts for HCPCS included on both the clinical diagnostic 
laboratory fee schedule and the SNF extract of the MPFS, the SNF receives the amount 
on the laboratory fee schedule. 
 
Payment is made for specimen collection fees and travel allowance as discussed in 
Medicare Claims Processing Manual, Chapter 16, "Laboratory Services from 
Independent Labs, Physicians, and Providers." 
  Bill type 22X for lab services to Part B residents and 23X for nonresidents should be 
used. 
 
Neither deductible nor coinsurance applies to lab fee schedule payments. 
 
See the Medicare Claims Processing Manual, Chapter 16, "Laboratory Services from 
Independent Labs, Physicians, and Providers," for additional coverage, billing, and 
payment requirements. 
 
90.1 - Glucose Monitoring 
(Rev. 1, 10-01-03) 
 
Medicare Part B may pay for a glucose monitoring device and related disposable supplies 
under its durable medical equipment benefit if the equipment is used in the home or in an 
institution that is used as a home.  A hospital or SNF is not considered a home under this 
benefit (1861(h) of the Act, 42 CFR 410.38). 
 
Routine glucose monitoring of diabetics is never covered in a SNF, whether the 
beneficiary is in a covered Part A stay or not.  Glucose monitoring may only be covered 
when it meets all the conditions of a covered laboratory service, including use by the 
physician in modifying the patient's treatment. 
 
100 - Epoetin (EPO) 
(Rev. 1, 10-01-03) 
SNF-543 
 
EPO is a biologically engineered protein which stimulates the bone marrow to make new 
red blood cells.  Patients with anemia associated with chronic renal failure include all 
ESRD patients regardless of whether they are on dialysis. 
 
EPO is covered for the treatment of anemia for patients with chronic renal failure who are 
receiving dialysis when it is administered in a renal dialysis facility (RDF). 
 
EPO is not included in SNF PPS and may be billed separately when given in conjunction 
with dialysis by the Renal Dialysis Facility.  It must be billed by the RDF. 
 
EPO is not a SNF outpatient benefit. 
 
110 - Carrier Claims Processing for Consolidated Billing for Physician 
and Non-Physician Practitioner Services Rendered to Beneficiaries in a 
Non-Covered SNF Stay 
(Rev. 846, Issued:  02-10-06; Effective:  12-15-05; Implementation:  03-13-06) 
 
For Medicare beneficiaries in a non-covered stay, only therapy services are subject to 
consolidated billing. All other covered SNF services must be separately billed to the 
carrier for payment consideration. Refer to section 110 in Chapter 6, SNF Inpatient Part  A Billing for additional information on carrier claims processing. A list of therapy codes 
that are subject to consolidated billing for beneficiaries in a non-covered SNF stay can be 
found on the CMS Web site at http://www.cms.hhs.gov/SNFConsolidatedBilling/. 
  Transmittals Issued for this Chapter 
Rev #  Issue Date  Subject  Impl Date  CR# 
R10880CP  08/06/2021  Internet Only Manual Updates to Pub.  11/08/2021  12009 
100-01, 100-02, and 100-04 to 
Implement Consolidated 
Appropriations Act Changes and 
Correct Errors and Omissions (SNF) 
R3481CP  03/18/2016  Updates to Pub. 100-04, Chapters 3, 6,  06/20/2016  9562 
7 and 15 to Correct Remittance Advice 
Messages 
R3053CP  08/28/2014  Update to Pub. 100-04, Chapters 7 and  09/30/2014  8579 
8 to Provide Language-Only Changes 
for Updating ICD-10 and ASC X12 
R2905CP  03/14/2014  Update to Pub. 100-04, Chapters 7 and  10/01/2014  8579 
8 to Provide Language-Only Changes 
for Updating ICD-10 and ASC X12  
Rescinded and replaced by Transmittal 
3053 
R1472CP  03/06/2008  Update of Institutional Claims  04/07/2008  5893 
References 
R1421CP  01/25/2008  Update of Institutional Claims  04/07/2008  5893 
References - Rescinded and Replaced 
by Transmittal 1472 
R980CP  06/14/2006  Changes Conforming to CR 3648  10/02/2006  4014 
Instructions for Therapy Services - 
Replaces Rev. 941 
R941CP  05/05/2006  Changes Conforming to CR 3648  10/02/2006  4014 
Instructions for Therapy Services 
R846CP  02/10/2006  New Skilled Nursing Facility  03/13/2006  4297 
Consolidated Billing Web site Address 
R685CP  09/23/2005  Discontinuation of the Skilled Nursing  12/27/2005  4044 
Facility (SNF) HCPCS Help File and 
Notification to Fiscal Intermediaries 
(FIs) and Providers of the Redesigned 
SNF Consolidated Billing (CB)  Annual Update File Posted on CMS 
Web Site 
R351CP  10/29/2004  Editing of Hospitals and Skilled  01/03/2005  3531 
Nursing Facilities Part B Inpatient 
Services (Full Replacement of Change 
Request 3366) 
R301CP  09/17/2004  Editing Of Hospital And Skilled  01/03/2005  3366 
Nursing Facility Part B Inpatient 
Services 
R251CP  07/23/2004  Editing Of Hospital And Skilled  01/03/2005  3366 
Nursing Facility Part B Inpatient 
Services 
R229CP  07/20/2004  Additional Clarification of Bill Types  08/19/2004  3323 
22x and 23x Submitted by Skilled 
Nursing Facilities (SNFs) With 
Instructions for Involuntarily Moving a 
Beneficiary Out of the SNF and 
Ending a Benefit Period 
R076CP  02/06/2004  SNF Inpatient Part A Billing  N/A  3133 
R020CP  10/31/2003  Add a paragraph regarding the SNF  11/05/2003  2968 
NO PAY FILE 
R001CP  10/01/2003  Initial Publication of Manual  NA  NA 
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