Medicare Claims Processing Manual 
Chapter 6 - SNF Inpatient Part A Billing and SNF 
Consolidated Billing 
 
Table of Contents 
(Rev. 12283; Issued: 10-05-23) 
 
 
Transmittals for Chapter 6 
 
10 - Skilled Nursing Facility (SNF) Prospective Payment System (PPS) and Consolidated 
Billing Overview 
10.1 - Consolidated Billing Requirement for SNFs 
10.2 - Types of Facilities Subject to the Consolidated Billing Requirement for 
SNFs 
10.3 - Types of Services Subject to the Consolidated Billing Requirement for 
SNFs 
10.4 - Furnishing Services that are Subject to SNF Consolidated Billing Under an 
Arrangement with an Outside Entity 
10.4.1 - Under Arrangements Relationships 
10.4.2 - SNF and Supplier Responsibilities 
20 - Services Included in Part A PPS Payment Not Billable Separately by the SNF 
20.1 - Services Beyond the Scope of the Part A SNF Benefit 
20.1.1 - Physicians Services and Other Professional Services Excluded 
From Part A PPS Payment and the Consolidated Billing Requirement 
20.1.1.1 - Correct Place of Service (POS) Code for SNF Claims 
20.1.1.2 - Hospitals Facility Charge in Connection with Clinic 
Services of a Physician 
20.1.2 - Other Excluded Services Beyond the Scope of a SNF Part A 
Benefit 
20.1.2.1 - Outpatient Surgery and Related Procedures- Inclusion 
20.1.2.2 - Emergency Services 
20.2 - Services Excluded from Part A PPS Payment and the Consolidated Billing 
Requirement on the Basis of Beneficiary Characteristics and Election 
20.2.1 - Dialysis and Dialysis Related Services to a Beneficiary With 
ESRD 
20.2.1.1 - ESRD Services 
20.2.1.2 - Coding Applicable to Dialysis Services Provided in a 
Renal Dialysis Facility (RDF) or Home) 
20.2.2 - Hospice Care for a Beneficiarys Terminal Illness  20.3 - Other Services Excluded from SNF PPS and Consolidated Billing 
20.3.1 - Ambulance Services 
20.4 - Screening and Preventive Services 
20.5 - Therapy Services 
20.6 - SNF CB Annual Update Proces for  A/B MACs (A) 
30 - Billing SNF PPS Services 
30.1 - Health Insurance Prospective Payment System (HIPPS) Rate Code 
30.2 - Coding PPS Bills for Ancillary Services 
30.3 - Adjustment Request 
30.4 - SNF PPS Pricer Software 
30.4.1 - Input/Output Record Layout 
30.4.2 - SNF PPS Rate Components 
30.4.3 - Decision Logic Used by the Pricer on Claims 
30.5 - Annual Updates to the SNF Pricer 
40 - Special Inpatient Billing Instructions 
40.1 - Submit Bills in Sequence 
40.2 - Reprocessing Inpatient Bills in Sequence 
40.3 - Determining Part A Admission Date, Discharge Date, and Utilization Days 
40.3.1 - Date of Admission 
40.3.2 - Patient Readmitted Within 30 Days After Discharge 
40.3.3 - Same Day Transfer 
40.3.4 - Situations that Require a Discharge or Leave of Absence 
40.3.5 - Determine Utilization on Day of Discharge, Death, or Day 
Beginning a Leave of Absence 
40.3.5.1 - Day of Discharge or Death Is the Day Following the 
Close of the Accounting Year 
40.3.5.2 - Leave of Absence 
40.4 - Accommodation Charges Incurred in Different Accounting Years 
40.5 - Billing Procedures for Periodic Interim Payment (PIP) Method of Payment 
40.6 - Total and Noncovered Charges 
40.6.1 - Services in Excess of Covered Services 
40.6.2 - Showing Discounted Charges 
40.6.3 - Reporting Accommodations on the Claim 
40.6.4 - Bills with Covered and Noncovered Days 
40.6.5 - Notification of Limitation on Liability Decision 
40.7 Ending a Benefit Period 
40.8 - Billing in Benefits Exhaust and No-Payment Situations 
40.8.1 - SNF Spell of Illness Quick Reference Chart 
40.8.2 - Billing When Qualifying Stay or Transfer Criteria are Not Met  40.9- Other Billing Situations 
50 - SNF Payment Bans, or Denial of Payment for New Admissions (DPNA) 
50.1 - Effect on Utilization Days and Benefit Period 
50.2 - Billing When Ban on Payment Is In Effect 
50.2.1 - Effect of an Appeal to a DPNA on Billing Requirements During 
the Period a SNF is Subject to a DPNA 
50.2.2 - Provider Liability Billing Instructions 
50.2.3 - Beneficiary Liability Billing Instructions 
50.2.4 - Part B Billing 
50.3 - Sanctions Lifted: Procedures for Beneficiaries Admitted During the 
Sanction Period 
50.3.1 - Tracking the Benefit Period 
50.3.2 - Determining Whether Transfer Requirements Have Been Met 
50.4 - Conducting Resident Assessments 
50.5 - Physician Certification 
50.6 - A/B MAC (A) Responsibilities 
50.7 - Retroactive Removal of Sanctions 
60 - Billing Procedures for a Composite SNF or a  Change in Provider Number 
70 - Billing for Services After Termination of Provider Agreement, or After Payment is 
Denied for New Admissions 
70.1 - General Rules 
70.2 - Billing for Covered Services 
70.3 - Part B Billing 
80 - Billing Related to Physicians Services 
80.1 - Reassignment Limitations 
80.2 - Payment to Employer of Physician 
80.3 - Information Necessary to Permit Payment to a Facility 
80.4 - Services Furnished Within the SNF 
80.5 - Billing Under Arrangements 
80.6 - Indirect Contractual Arrangement 
80.7 - Establishing That a SNF Qualifies to Receive Part B Payment on the Basis 
of Reassignment 
90 - Medicare Advantage (MA) Beneficiaries 
90.1 - Beneficiary Disenrolled from MA Plans 
90.2 - Medicare Billing Requirements for Beneficiaries Enrolled in MA Plans 
100 - Part A SNF PPS for Hospital Swing Bed Facilities 
100.1 - Swing Bed Services Not Included in the Part A PPS Rate 
110 - A/B MAC (B)/DME MAC Claims Processing for Consolidated Billing for 
Physician and Non-Physician Practitioner Services Rendered to Beneficiaries in a SNF 
Part A Stay  110.1 - Correct Place of Service (POS) Code for SNF Claims 
110.2 - CWF Edits 
110.2.1 - Reject and Unsolicited Response Edits 
110.2.2 - A/B Crossover Edits 
110.2.3 - Duplicate Edits 
110.2.4 - Edit for Ambulance Services 
110.2.5 - Edit for Clinical Social Workers (CSWs) 
110.2.6 - Edit for Therapy Services Separately Payable When Furnished 
by a Physician 
110.2.7 - Edit to Prevent Payment of Facility Fees for Services Billed by 
an Ambulatory Surgical Center (ASC) when Rendered to a Beneficiary in 
a Part A Stay 
110.3 - CWF Override Codes 
110.4 - Coding Files and Updates 
110.4.1 - Annual Update Process 
 120- Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) 
  120.1 - HIPPS Updates and Structure Changes 
  120.2 - Interrupted Stay Policy 
  120.3 - Variable Per Diem (VPD) Adjustment 
  120.4 - AIDS Adjustments 
  120.5 - Transition Claims 
  120.6 - Default Billing 
  10 - Skilled Nursing Facility (SNF) Prospective Payment System (PPS) 
and Consolidated Billing Overview 
(Rev.4163, Issued: 11-02-18, Effective: 12-04-18, Implementation: 12-04-18) 
 
All SNF Part A inpatient services are paid under a prospective payment system (PPS).  
Under SNF PPS, beneficiaries must meet the regular eligibility requirements for a SNF 
stay.  That is, the beneficiary must have been an inpatient of a hospital for a medically 
necessary stay of at least three consecutive calendar days.  In addition, the beneficiary 
must have been transferred to a participating SNF within 30 days after discharge from the 
hospital, unless the patients condition makes it medically inappropriate to begin an 
active course of treatment in an SNF within 30 days after hospital discharge, and it is 
medically predictable at the time of the hospital discharge that the beneficiary will 
require covered care within a predetermined time period.  (See the Medicare Benefit 
Policy Manual, Chapter 8, Coverage of Extended Care Services Under Hospital 
Insurance, 20.2, for further information on the 30-day transfer requirement and 
exception.)  To be covered, the extended care services must be needed for a condition 
which was treated during the patients qualifying hospital stay, or for a condition which 
arose while in the SNF for treatment of a condition for which the beneficiary was 
previously treated in a hospital. 
Also under SNF PPS all Medicare covered Part A services that are considered within the 
scope or capability of SNFs are considered paid in the PPS rate.  In some cases this 
means that the SNF must obtain some services that it does not provide directly.  Neither 
the SNF nor another provider or practitioner may bill the program for the services under 
Part B, except for services specifically excluded from PPS payment and associated 
consolidated billing requirements. 
Any DME or oxygen furnished to inpatients in a covered Part A stay is included in the 
SNF PPS rate.  The definition of DME in 1861(n) of the Social Security Act (the Act) 
provides that DME is covered by Part B only when intended for use in the home, which 
explicitly does not include a SNF.  This definition applies to oxygen also.  (See the 
Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health 
Service, 110.) 
Most prosthetics and all orthotic devices are included in the Part A PPS rate.  An 
exception involves certain designated customized prosthetic devices that are specifically 
identified as being outside the rate (see the regulations at 42 CFR 411.15(p)(2)(xvi) and 
Major Category III.D of the SNF consolidated billing editing).  Those customized 
prosthetic devices that are considered outside the PPS rate are billed by the qualified 
outside entity that furnished the service.  That entity bills its normal MAC. 
 
Services that are not considered to be furnished within SNF PPS are identified in sections 
20.1 - 20.4.  These may be billed separately under Part B.  Some services must be 
billed by the SNF.  (This is referred to as consolidated billing.)  Some services must be 
billed by the rendering provider (SNF or otherwise).  These are discussed further in 
20.1 - 20.4.   
10.1 - Consolidated Billing Requirement for SNFs 
(Rev.4163, Issued: 11-02-18, Effective: 12-04-18, Implementation: 12-04-18) 
  
Section 4432 (b) of the Balanced Budget Act (BBA) requires consolidated billing (CB) 
for SNFs.  Under the CB requirement, the SNF must submit ALL Medicare claims for 
ALL the services that its residents receive under Part A, except for certain excluded 
services described in 20.1 - 20.3, and for all physical, occupational and speech-
language pathology services received by residents under Part B (see 20.5).  A SNF 
resident is defined as a beneficiary who is admitted to a Medicare participating SNF or 
the participating, Medicare-certified, distinct part unit (DPU) of a larger institution.  
Under the regulations at 42 CFR 411.15(p)(3)(i)-(iv), if  such a beneficiary leaves the 
facility (or the DPU), the beneficiarys status as a SNF resident for CB purposes (along 
with the SNFs responsibility to furnish or make arrangements for needed services) ends 
when any one of the following events occurs: 
 
  The beneficiary is admitted as an inpatient to a Medicare-
participating hospital or critical access hospital (CAH), or as a 
resident to another SNF; 
 
  The beneficiary receives services from a Medicare-participating 
home health agency under a plan of care; 
 
  The beneficiary receives one of the types of outpatient hospital 
services that CMS has designated as being exceptionally intensive 
(see 20.1.2); or 
 
  The beneficiary is formally discharged (or otherwise departs) from 
the SNF or DPU, unless the beneficiary is readmitted (or returns) 
to that or another SNF before the following midnight. This 
provision is sometimes referred to as the midnight rule (see Pub. 
100-02, Medicare Benefit Policy Manual, chapter 3, 20.1, which 
specifies that an inpatient day . . . begins at midnight and ends 24 
hours later).  A discharge from the Medicare-certified DPU 
includes situations in which the beneficiary is moved from the 
DPU to a Medicare non-certified area within the same institution. 
 
When a beneficiary is absent from the SNF overnight (i.e., the absence from the SNF 
spans midnight), the beneficiarys status as a SNF resident for CB purposes would end 
upon the point of departure from the SNF (per the above-described midnight rule), and 
would not resume until the actual point of arrival back at the SNF the next day. 
Accordingly, that beneficiary would not be considered a SNF resident for CB purposes 
between those two points, so that any offsite services furnished during the interim (such 
as an overnight sleep study) would not be subject to CB. 
 
It should be noted that the scenarios described in the first three clauses above would 
become relevant only if a beneficiary leaves the SNF but then arrives back in that or  another SNF before the following midnight.  This is because under the midnight rule 
discussed in the fourth clause, whenever a beneficiary leaves the SNF but does not arrive 
back in that or another SNF later on that same day, the beneficiarys resident status for 
CB purposes would end immediately upon departure--before any of the other events 
described in the first three clauses could even occur. 
 
By contrast, when a beneficiary does return to that or another SNF by the end of the same 
day (a scenario that normally would serve to maintain the beneficiarys status as a 
resident of the originating SNF throughout the absence), the occurrence of one of the 
intervening events listed in the first three clauses above would nevertheless serve to end 
the beneficiarys resident status at that point.  For example, when a beneficiary leaves 
the SNF to receive outpatient emergency services at the hospital, the emergency services 
would never be subject to CBeven in a situation where the beneficiary returns to the 
SNF later that same daybecause the receipt of the emergency services themselves 
under the third clause above would have already served to suspend the beneficiarys SNF 
resident status with respect to those services under the regulations at 42 CFR 
411.15(p)(3)(iii). 
 
These requirements apply only to Medicare fee-for-service beneficiaries residing in a 
participating SNF or DPU. 
 
Claims are submitted to the A/B MAC (A) on the ASC X12 837 institutional format or 
Form CMS-1450.  All services billed by the SNF (including those furnished under 
arrangements with an outside supplier) for a resident of a SNF in a covered Part A stay 
are included in the SNFs Part A bill.  If a resident is not in a covered Part A stay (Part A 
benefits exhausted, posthospital or level of care requirements not met), the SNF is 
required to bill for all physical therapy, occupational therapy, and/or speech-language 
pathology services provided to a SNF resident under Part B.  The CB provision requires 
that effective for services and items furnished on or after July 1, 1998, payment is made 
directly to the SNF. 
 
Thus, SNFs are no longer able to unbundle services to an outside supplier that can then 
submit a separate bill directly to an A/B MAC (B) or DME MAC for residents in a Part A 
stay, or for SNF residents receiving physical therapy, occupational therapy, and/or 
speech-language pathology services paid under Part B.  Instead, the SNF must furnish the 
services either directly or under an arrangement with an outside supplier or provider of 
services in which the SNF (rather than the supplier or provider of services) bills 
Medicare.  Medicare does not pay amounts that are due a provider to any other person 
under assignment, or power of attorney, or any other direct payment arrangement.  As a 
result, the outside supplier must look to the SNF (rather than the A/B MAC (A), or (B), 
or DME MAC or the beneficiary) for payment.  The SNF may collect any applicable 
deductible or coinsurance from the beneficiary. 
 
NOTE:  The requirements for participation at 42 CFR 483.15(c)(1)(i)(A)-(F) specify the 
limited circumstances under which a resident can be involuntarily moved out of a 
Medicare-certified SNF or DPU.  These circumstances can include situations in which 
the resident's health has improved to the point where he or she no longer needs SNF care.   However, if a resident has exhausted Part A benefits but nevertheless continues to require 
SNF care, he or she cannot be moved out of the Medicare-certified SNF or DPU for 
reasons other than those specified in the regulations.  For example, the resident cannot be 
moved to avoid the CB requirements, or to establish a new benefit period.  The 
determination to move the beneficiary out of the SNF or DPU must not be made on the 
basis of the beneficiary having exhausted his or her benefits, but rather, on the 
beneficiary's lack of further need for SNF care.  Once a resident of a Medicare-certified 
DPU ceases to require SNF care, he or she may then be moved from the DPU to the 
Medicare non-certified area of the institution.  As discussed above, such a move would 
end the beneficiary's status as a SNF "resident" for CB purposes. 
 
Enforcement of CB is done through editing in Medicare claims processing systems using 
lists of Healthcare Common Procedure Coding System (HCPCS) codes that are subject to 
the CB provision of SNF PPS.  In order to assure proper payment in all settings, 
Medicare systems must edit for services, provided to SNF beneficiaries, both included 
and excluded from CB.  Transmittals with instructions provide updates to previous lists 
of the exclusions, and some inclusions, to CB.  Such transmittals can be found on the 
CMS Web site at:  https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html or 
http://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html.  Step-by-step 
instructions for accessing the exclusion list itself appear in the Medicare Benefit Policy 
Manual, Chapter 8, 10.2. 
 
The list of HCPCS codes enforcing CB may be updated each quarter.  For the notice on 
CB for the quarter beginning January, separate instructions are published for A/B MACs 
(A) and A/B MACs (B)/DME MACs.  Since this is usually the only quarter in which new 
permanent HCPCS codes are produced, this recurring update is referred to as an annual 
update.  Other updates for the remaining quarters of the year will occur as needed prior to 
the next annual update.  In lieu of another update, editing based on the prior list of codes 
remains in effect.  Some non-January quarterly updates may apply to each of A/B MACs 
(A) and (HHH) and A/B MACs (B)/DME MACs, and the applicability of the instruction 
will be clear in each update.  All future updates will be submitted via a Recurring Update 
Notification form. 
 
  Effective July 1, 1998, CB became effective for those services and items that were 
not specifically excluded by law from the SNF prospective payment system (PPS) 
when they were furnished to residents of a SNF in a covered Part A stay and also 
includes physical therapy, occupational therapy, and/or speech-language pathology 
services in a noncovered stay.  SNFs became subject to CB once they transitioned 
to PPS.  Due to systems limitations, CB was not implemented at that time for 
residents not in a Part A covered stay (Part A benefits exhausted, post-hospital or 
level of care requirements not met).  Section 313 of the Benefits Improvement and 
Protection Act (BIPA) of 2000 subsequently repealed this aspect of CB altogether, 
except for physical therapy, occupational therapy, and/or speech-language 
pathology services.  In addition, for either type of resident, the following 
requirements were also delayed: (1) that the physicians forward the technical  portions of their services to the SNF; and (2) the requirement that the physician 
enter the facility provider number of the SNF on the claim. 
 
  Effective July 1, 1998, under 42 CFR 411.15(p)(3)(iii) published on May 12, 
1998, a number of other services are excluded from CB.  The hospital outpatient 
department will bill these services directly to the A/B MAC (A) when furnished on 
an outpatient basis by a hospital or a critical access hospital (see 20.1.2).  
Physicians and other practitioners professional services will be billed directly to 
the A/B MAC (B) (see 20.1.1).  Hospice care (see 20.2.2) and the ambulance 
trip that initially conveys an individual to the SNF to be admitted as a resident, or 
that conveys an individual from the SNF when discharged and no longer 
considered a resident (see 20.3), are also excluded from CB. 
 
  Effective April 1, 2000, 103 of the Balanced Budget Refinement Act (BBRA) 
excluded additional services and drugs from CB that therefore had to be billed 
directly to the A/B MAC (B) or DME MAC by the provider or supplier for 
payment (see 20.3).  As opposed to whole categories of services being excluded, 
only certain specific services and drugs (identified by HCPCS code) were excluded 
in each category.  These exclusions included ambulance services furnished in 
conjunction with renal dialysis services, certain specific chemotherapy drugs and 
their administration services, certain specific radioisotope services, and certain 
customized prosthetic devices. 
 
  Effective January 1, 2001, 313 of the BIPA, restricted CB to the majority of 
services provided to beneficiaries in a Medicare Part A covered stay and only to 
therapy services provided to beneficiaries in a noncovered stay (see 20.5). 
 
  Effective for claims with dates of service on or after April 1, 2001, for 
those services and supplies that were not specifically excluded by law and 
are furnished to a SNF resident covered under the Part A benefit, 
physicians are required to forward the technical portions of any services to 
the SNF to be billed by the SNF to the A/B MAC (A) for payment (see 
20.1.1). 
 
10.2 - Types of Facilities Subject to the Consolidated Billing 
Requirement for SNFs 
(Rev. 4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11- 05-19) 
Consolidated billing applies to: 
 
  Participating SNFs; 
  Short term hospitals, long term hospitals, and rehabilitation hospitals certified as 
swing-bed hospitals, except critical access hospitals (CAHs) certified as swing 
bed hospitals (however, while a CAHs SNF-level swing bed services are not 
subject to consolidated billing, they remain subject to the bundling requirement 
for hospitals, as specified in the Medicare Claims Processing Manual, Chapter 3, 
60).  Rural (non-CAH) swing bed hospitals that furnish SNF-level services are  subject to both the consolidated billing and hospital bundling requirements (see 
100.1); accordingly, as explained in the FY 2002 SNF PPS final rule (66 FR 
39593, July 31, 2001), for the small number of services (such as dialysis) that are 
excluded from consolidated billing but remain subject to hospital bundling, the 
billing responsibility would remain with the rural swing bed hospital itself (in 
accordance with the hospital bundling requirement), but it would use a separate 
inpatient Part B claim to bill for those services outside of the bundled SNF PPS 
rate (in recognition of their exclusion from the consolidated billing requirement).  
 
But consolidated billing does not apply to: 
 
  A nursing home that is not Medicare-certified, such as: 
 
o  A nursing home that does not participate at all in either the Medicare or 
Medicaid programs; 
 
o  A non-certified part of a nursing home that also includes a participating 
distinct part SNF unit; and 
 
o  A nursing home that exclusively participates in the Medicaid program as 
an NF. 
 
  CAHs certified as swing-bed hospitals.  However, as noted above, CAH swing-
bed services are subject to the hospital bundling requirement at section 
1862(a)(14) of the Social Security Act and 42 CFR  411.15(m).  
 
Medicare Coordinated Care Demonstration 
Services for beneficiaries covered under the Medicare Coordinated Care Demonstration 
will not be subject to consolidated billing.  Common Working File (CWF) will 
appropriately edit for these codes so that the A/B MACs (B) will pay them separately. 
 
10.3 - Types of Services Subject to the Consolidated Billing 
Requirement for SNFs 
(Rev. 2573, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13) 
 
As previously discussed, the consolidated billing requirement applies to all services 
furnished to a SNF resident in a covered Part A stay (other than the excluded service 
categories described below) and for physical therapy, occupational therapy, and/or 
speech-language pathology services provided to residents and paid under Part B. 
Examples of services that are subject to consolidated billing include: 
 
  Physical therapy, occupational therapy, and/or speech-language pathology 
services, regardless of whether they are furnished by (or under the supervision of)  a physician or other health care professional (see 1888(e)(2)(A)(ii) of the Act).  
Physical therapy, occupational therapy, and/or speech-language pathology 
services (other than audiology services, which are considered diagnostic tests 
rather than therapy services) furnished to a SNF resident during a noncovered stay 
must still be billed by the SNF itself.  This is known as Part B consolidated 
billing (see 20.5 of this chapter). 
 
  Psychological and other services furnished by a clinical social worker; and  
 
  Services furnished as an incident to the professional services of a physician or 
other excluded category of health care professional described in 20.1.1 below. 
 
10.4 - Furnishing Services that are Subject to SNF Consolidated Billing 
Under an Arrangement With an Outside Entity 
(Rev .4001, Issued: 03-16-18, Effective: 06- 19- 18, Implementation: 06-19-18) 
 
As discussed in 10.1 and 10.3, the SNF consolidated billing provisions (at 
1862(a)(18), 1866(a)(1)(H)(ii), and 1888(e)(2)(A) of the Act) place with the SNF 
itself the Medicare billing responsibility for most of its residents services.  Part A 
consolidated billing requires that a SNF must include on its Part A bill almost all of the 
services that a resident receives during the course of a Medicare-covered stay, other than 
those services that are specifically excluded from the SNFs global PPS per diem 
payment for the covered stay.  (These excluded services, such as the services of 
physicians and certain other practitioners, remain separately billable to the A/B MAC (B) 
directly by the outside entity that actually furnishes them.)  In addition, Part B 
consolidated billing makes the SNF itself responsible for submitting the Part B bills for 
any physical therapy, occupational therapy, and/or speech-language pathology services 
that a resident receives during a noncovered stay (see 20.5). 
 
Further, for any Part A or Part B service that is subject to SNF consolidated billing, the 
SNF must either furnish the service directly with its own resources, or obtain the service 
from an outside entity (such as a supplier) under an arrangement, as described in 
1861(w) of the Act and in 80.5.  Under such an arrangement, the SNF must reimburse 
the outside entity for those Medicare-covered services that are subject to consolidated 
billing; i.e., services that are reimbursable only to the SNF as part of its global PPS per 
diem or those Part B services that must be billed by the SNF. 
 
Since the inception of the SNF PPS, several problematic situations have been identified 
where the SNF resident receives services that are subject to consolidated billing from an 
outside entity, such as a supplier.  (In this context, the term supplier can also include 
those practitioners who, in addition to performing their separately billable professional 
services, essentially act as a supplier by also furnishing other services that are subject to 
the consolidated billing requirement.)  As discussed in greater detail below, such 
situations most commonly arise in one of the following two scenarios:  1) A SNF does  not accurately identify services as being subject to consolidated billing when ordering 
such services from a supplier or practitioner; or 2) A supplier fails to ascertain a 
beneficiarys status as a SNF resident when the beneficiary (or another individual acting 
on the beneficiarys behalf) seeks to obtain such services directly from the supplier 
without the SNFs knowledge. 
 
The absence of a valid arrangement in the situations described above creates confusion 
and friction between SNFs and their suppliers.  Suppliers need to understand which 
services are subject to consolidated billing to avoid situations where they might 
improperly attempt to bill the A/B MAC (B) (or other payers such as Medicaid and 
beneficiaries) directly for the services.  In addition, when ordering or furnishing services 
under arrangements, both parties need to reach a common understanding on the terms 
of payment; e.g., how to submit an invoice, how payment rates will be determined, and 
the turn-around time between billing and payment.  Without this understanding, it may 
become difficult to maintain the strong relationships between SNFs and their suppliers 
that are necessary to ensure proper coordination of care to the Medicare beneficiaries.  
Whenever possible, SNFs should document arrangements with suppliers in writing, 
particularly with suppliers furnishing services on an ongoing basis, such as laboratories, 
x-ray suppliers, and pharmacies.  This also enables the SNF to obtain the suppliers 
assurance that the arranged-for services will meet accepted standards of quality (under 
the regulations at 42 CFR 483.70(g)(2), SNFs must ensure that services obtained under 
an arrangement with an outside source meet professional standards and principles that 
apply to professionals providing such services). 
 
However, it is important to note that the absence of a valid arrangement does NOT 
invalidate the SNFs responsibility to reimburse suppliers for services included in the 
SNF bundle of services represented by the SNF PPS global per diem rate.  As the SNF 
has already been paid for the services, the SNF must be considered the responsible party 
when medically necessary supplier services are furnished to beneficiaries in Medicare 
Part A stays.  This obligation applies even in cases where the SNF did not specifically 
order the service; e.g., during a scheduled physicians visit, the physician performs 
additional diagnostic tests that had not been ordered by the SNF; a family member 
arranges a physician visit without the knowledge of SNF staff and the physician bills the 
SNF for incident to services. 
 
Finally, while establishing a valid arrangement prior to ordering services from a supplier 
minimizes the likelihood of a payment dispute between the parties, it is not unreasonable 
to expect occasional disagreements between the parties that may result in non-payment of 
a supplier claim.  However, it is important to note that there are potentially adverse 
consequences to SNFs when patterns of such denials are identified.  Specifically, all 
participating SNFs agree to comply with program regulations when entering into a 
Medicare provider agreement which, as explained below, requires a SNF to have a valid 
arrangement in place whenever a resident receives services that are subject to 
consolidated billing from any entity other than the SNF itself.  Moreover, in receiving a  bundled per diem payment under the SNF PPS that includes such services, the SNF is 
accepting Medicare payment, and financial responsibility, for the service. 
 
Accordingly, these instructions reiterate and clarify the applicable consolidated billing 
requirements that pertain to SNFs and to the outside suppliers that serve SNF residents. 
 
10.4.1 - Under Arrangements Relationships 
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21) 
 
Under an arrangement as defined in 1861(w) of the Act, Medicares payment to the SNF 
represents payment in full for the arranged-for service, and the supplier must look to the 
SNF (rather than to A/B MAC (B)) for its payment.  Further, in entering into such an 
arrangement, the SNF cannot function as a mere billing conduit, but must actually 
exercise professional responsibility over the arranged-for service (see the Medicare 
General Information, Eligibility, and Entitlement Manual, Chapter 5, 10.3, and the 
Medicare Benefit Policy Manual, Chapter 8, 70.4, for additional information on services 
furnished under arrangements). 
 
Medicare does not prescribe the actual terms of the SNFs relationship with its suppliers 
(such as the specific amount or timing of payment by the SNF), which are to be arrived at 
through direct negotiation between the parties to the agreement.  However, in order for a 
valid arrangement to exist, the SNF must reach a mutual understanding with its 
supplier as to how the supplier is to be paid for its services.  Documenting the terms of 
the arrangement confers the added benefit of providing both parties with a ready means 
of resolution in the event that a dispute arises over a particular service.  This type of 
arrangement has proven to be effective in situations where suppliers regularly provide 
services to facility residents on an ongoing basis; e.g., laboratory and x-ray suppliers, 
DME supplies, etc.  Sample model agreements involving arrangements between SNFs 
and their suppliers are available for review on CMSs Best Practices Guidelines 
website, at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/SNFPPS/BestPractices.html. 
 
If a SNF elects to utilize an outside supplier to furnish medically appropriate services that 
are subject to consolidated billing, but then refuses to reimburse that supplier for the 
services, then there is no valid arrangement as contemplated under 1862(a)(18) of the 
Act.  Not only would this potentially result in Medicares noncoverage of the particular 
services at issue, but a SNF demonstrating a pattern of nonpayment would also risk being 
found in violation of the terms of its provider agreement.  Under 1866(a)(1)(H)(ii) of the 
Act (and 42 CFR 489.20(s)), the SNFs provider agreement includes a specific 
commitment to comply with the requirements of the consolidated billing provision.  
Further, 1866(g) of the Act imposes a civil money penalty on any person who 
knowingly and willfully presents (or causes to be presented) a bill or request for payment 
inconsistent with an arrangement or in violation of the requirement for such an 
arrangement. 
  10.4.2 - SNF and Supplier Responsibilities 
(Rev. 412, Issued: 12-23-04, Effective: 05-21-04, Implementation: 01-24-05) 
 
Problems involving the absence of a valid arrangement between an SNF and its suppliers 
typically tend to arise in one of the following two situations. 
 
Problem Scenario 1:  An SNF elects to utilize an outside supplier to furnish a 
type of service that would be subject to Part A consolidated billing, but then 
fails to inform the supplier that the resident receiving the service is in a 
covered Part A stay.  This causes the supplier to conclude mistakenly that the 
service it furnishes to that resident is not subject to consolidated billing. 
 
Based on the inaccurate impression that the residents SNF stay is 
noncovered, the supplier inappropriately submits a separate Part B claim for 
the service, and may also improperly bill other insurers and the resident.  
Then, the supplier only learns of the actual status of the residents Medicare-
covered SNF stay when that Part B claim is denied.  In this scenario, even 
though the supplier made reasonable efforts to ascertain from the SNF both 
the beneficiarys status as an SNF resident and the specific nature of the 
beneficiarys SNF stay, the information from the SNF (on which the supplier 
relied) proved to be inaccurate. 
 
While we recognize that inadvertent errors may occasionally occur in the course of 
furnishing such information, an SNF should not only make a good faith effort to furnish 
accurate information to its supplier, but must reimburse the supplier once such an error is 
called to its attention.  If, in the scenario at issue, the SNF refuses to pay the supplier for 
the service even after being apprised of the inaccuracy of its initial information, the SNF 
would not be in compliance with consolidated billing requirements.  As discussed 
previously, having supporting documentation in place for the disputed service would not 
only help to ensure compliance with the consolidated billing requirements, but should 
also provide a vehicle for resolving the dispute itself. 
 
Of course, the SNF can often prevent such disputes from arising to begin with, simply by 
ensuring that the supplier receives accurate and timely information about the status of a 
residents Medicare-covered SNF stay.  The SNFs responsibility to communicate 
accurate and timely resident information to its suppliers is especially important in those 
instances where a particular portion of an otherwise bundled service remains separately 
billable to Part B (for example, the professional component that represents a physicians 
interpretation of an otherwise bundled diagnostic test). 
 
Problem Scenario 2:  A resident temporarily departs from the SNF on a brief 
leave of absence, typically accompanied by a relative or friend.  While briefly 
offsite, the resident (or the relative or friend, acting on the residents behalf) 
obtains services that are subject to the consolidated billing requirement, but fails 
to notify the SNF.  The SNF refuses to pay for the offsite services, and the 
supplier bills the beneficiary/family member directly. 
  As in the previous scenario, the SNF remains responsible for any services included in the 
SNF bundle of services subject to consolidated billing that are furnished to the resident 
by an outside entity, even in the absence of a valid arrangement with the SNF. 
The SNFs can act to prevent such problems from arising by ensuring that each resident 
(and, if applicable, his or her representative) is fully aware of the applicable 
requirements.  For example, while the Medicare law at 1802 of the Act guarantees a 
beneficiarys free choice of any qualified entity that is willing to furnish services to the 
beneficiary, in selecting a particular SNF, the beneficiary has effectively exercised this 
right of free choice with respect to the entire package of services for which the SNF is 
responsible under the consolidated billing requirement, including the use of any outside 
suppliers from which the SNF chooses to obtain such services.  SNF staff need to 
communicate these requirements to beneficiaries and family members upon admission.  
Further, in providing such advice periodically throughout each residents stay, the SNF 
should take particular care to include any resident who is about to leave the facility 
temporarily, in order to ensure that the resident (and, if applicable, the residents 
representative) understands the need to consult the SNF before obtaining any services 
offsite. 
 
Moreover, while the SNF itself should take reasonable steps to prevent such problems 
from arising, the supplier in this scenario is also responsible for being aware of and 
complying with the consolidated billing requirements.  This means that prior to 
furnishing services to a Medicare beneficiary, the supplier should routinely ascertain 
whether the beneficiary is currently receiving any comprehensive Medicare benefits 
(such as SNF or home health benefits) for which Medicare makes a bundled payment that 
could potentially include the suppliers services.  If the supplier ascertains that a 
particular beneficiary is, in fact, a resident of an SNF with which the supplier does not 
have a valid arrangement in place, then the supplier should contact the SNF before 
actually furnishing any services to that beneficiary that are subject to the consolidated 
billing provision.  Further, under the regulations at 42 CFR 489.21(h), the beneficiary 
cannot be charged for the bundled services. 
 
20 - Services Included in Part A PPS Payment Not Billable Separately 
by the SNF 
(Rev. 2573, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13) 
 
For cost reporting periods beginning on and after July 1, 1998, SNF services paid under 
Part A include posthospital SNF services for which benefits are provided under Part A, 
and all items and services which, prior to July 1, 1998, had been paid under Part B but 
furnished to SNF residents during a Part A covered stay regardless of source, except for 
the exclusions listed in the annual SNF consolidated billing update files.  Annual update 
files, as well as subsequent quarterly updates to the annual update, for SNF consolidated 
billing can be found at http://www.cms.hhs.gov/SNFConsolidatedBilling/.  This file lists 
services by HCPCS code, short descriptors, and the major category under which the 
HCPCS falls.  HCPCS added or removed by subsequent quarterly update transmittals will 
be listed under the respective years annual update at the above link.  The respective 
years annual update file will be updated to add or remove the HCPCS listed in the 
quarterly updates.   
A general explanation of the five major categories can also be found at the above link. 
 
NOTE: It is important for MACs/providers to understand the major categories for SNF 
CB.  Some major categories exclude services by revenue code (see section 20.1.2.2 for 
emergency room exclusion) as well as bill types (see section 20.2.1.2 on coding for renal 
dialysis facilities and 20.2.2 for hospice facilities). 
 
Services paid under Part A cannot be billed under Part B.  Any service paid under Part A 
that is billed separately will not be paid separately, or payment will be recovered if 
already paid at the time of the SNF billing.  The following subsections list the types of 
services that can be billed under Part B for SNF residents for whom Part A payment is 
made. 
 
20.1 - Services Beyond the Scope of the Part A SNF Benefit 
(Rev. 846, Issued:  02-10-06; Effective:  12-15-05; Implementation:  03-13-06) 
 
The following services are beyond the scope of the SNF Part A benefit and are excluded 
from payment under Part A SNF PPS and from the requirement for consolidated billing.  
These services must be paid to the practitioner or provider that renders them and are 
billed separately by the rendering provider/supplier/practitioner to the A/B MAC (A) or 
(B).  The SNF may not bill excluded services separately under Part B for its inpatients 
entitled to Part A benefits.  HCPCS procedure codes representing these excepted services 
for services billed to the A/B MACs (A), (B), (HHH), and DME MACs are updated as 
frequently as quarterly on the CMS Web site at:  
https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/  Physicians, non-
physician practitioners, and suppliers billing the A/B MAC (B) should consult the above 
link for lists of separately billable services.   
 
Note:  There are separate Annual Update files for service billed to A/B MACs (B)/DME 
MACs and services billed to A/B MACs (A) or (HHH) posted to the Web site mentioned 
above. 
 
20.1.1 - Physicians Services and Other Professional Services Excluded 
From Part A PPS Payment and the Consolidated Billing Requirement 
(Rev. 12283, Issued:10-05-23, Effective:01-08-24, Implementation:01-08-24)  
Except for the therapy services (see 20.5), physicians professional services and 
services of certain nonphysician providers listed below are excluded from Part A PPS 
payment and the requirement for consolidated billing, and must be billed separately by 
the practitioner to the A/B MAC (B).  See below for Rural Health Clinic 
(RHC)/Federally Qualified Health Center (FQHC) instructions.  
For this purpose physician service means the professional services of the physician as 
defined under the Medicare physician Fee Schedule.  For services that contain both a 
technical component and a professional component, the technical component, if any, 
must be billed by the SNF for its Part A inpatients.  The A/B MAC (B) will pay only the  professional component to the physician.  For example, the technical component of a 
diagnostic radiology test (representing the performance of the procedure itself) is subject 
to SNF CB, whereas the professional component (representing the physicians 
interpretation of the test results) is excluded and, thus, remains separately billable under 
Part B.  
  
  Physicians services other than physical, occupational, and speech 
language pathology services furnished to SNF residents;  
  
  Physician assistants, working under a physicians supervision;  
  
  Nurse practitioners and clinical nurse specialists working in collaboration 
with a physician;  
  
  Certified nurse-midwives;  
  
  Qualified psychologists; 
 
  Marriage and family therapists; 
 
  Mental health counselors; and 
  
  Certified registered nurse anesthetists.  
  
SNF CB excludes the categories of practitioner services described above, and this 
exclusion applies specifically to those professional services that ordinarily require 
performance by the practitioner personally (see the regulations at 42 CFR 411.15(p)(2)(i) 
and 415.102(a)(3)).  This means, for example, that an otherwise bundled task (such as a 
routine blood draw) cannot be converted into an excluded physician service merely by 
having a physician perform it personally, as such a task does not ordinarily require 
performance by the physician.  This exclusion also does not encompass services that are 
performed by someone else as an incident to the practitioners professional service.  Such 
incident to services remain subject to SNF CB and, accordingly, must be billed to 
Medicare by the SNF itself (see 10.3).  
  
Providers with the following specialty codes assigned by CMS upon enrollment with  
Medicare are considered physicians for this purpose.  Some limitations are imposed by 
1861(q) and (r) of the Act.  These providers may bill their A/B MAC (B) directly.  
  
Physician Specialty Codes  
01  General Practice   02  General Surgery   03  Allergy/Immunology   04  Otolaryngology  
05  Anesthesiology   06  Cardiology  
07  Dermatology   08  Family Practice  
10  Gastroenterology   11  Internal Medicine  
Physician Specialty Codes  
12  Osteopathic Manipulative Therapy   13  Neurology  
14  Neurosurgery   16  Obstetrics Gynecology  
18  Ophthalmology   19  Oral Surgery (Dentists only)  
20  Orthopedic Surgery   22  Pathology  
24  Plastic and Reconstructive Surgery   25  Physical Medicine and Rehabilitation  
26  Psychiatry   28  Colorectal Surgery (formerly Proctology)  
29  Pulmonary Disease   30  Diagnostic Radiology  
33  Thoracic Surgery   34  Urology  
35  Chiropractic   36  Nuclear Medicine  
37  Pediatric Medicine   38  Geriatric Medicine  
39  Nephrology   40  Hand Surgery  
41  Optometry   44  Infectious Disease  
46  Endocrinology   48  Podiatry  
66  Rheumatology   69  Independent Labs  
70  Multi specialty Clinic or Group Practice   76  Peripheral Vascular Disease  
77  Vascular Surgery   78  Cardiac Surgery  
79  Addiction Medicine   81  Critical Care (Intensivists)  
82  Hematology   83  Hematology/Oncology  
84  Preventive Medicine   85  Maxillofacial Surgery  
86  Neuropsychiatry   90  Medical Oncology  
91  Surgical Oncology   92  Radiation Oncology  
93  Emergency Medicine   94  Interventional Radiology  
98  Gynecological/Oncology   99  Unknown Physician Specialty  
Nonphysician Provider Specialty Codes  
42  Certified Nurse Midwife   43  Certified Registered Nurse Anesthetist,  
Anesthesia Assistants (effective 1/1/89)  
50  Nurse Practitioner   62  Clinical Psychologist  (billing 
independently)  
68  Clinical Psychologist   89  Certified Clinical Nurse Specialist   97  Physician Assistant     
  
NOTE:  Some HCPCS codes are defined as all professional components in the fee 
schedule.  Fee schedule definitions apply for this purpose.  
Effective July 1, 2001, the Benefits Improvement and Protection Act (BIPA) established 
payment method II, in which CAHs can bill and be paid for physician services billed to 
their A/B MAC (A).  CAHs must bill the professional fees using revenue codes 96x, 97x, 
or 98x on an 85x type of bill (TOB).  Like professional services billed to the A/B MAC 
(B), the specific line items containing these revenue codes for professional services are 
excluded from the requirement for consolidated billing.  
RHC/FQHC Instructions:  
  
Effective January 1, 2005, section 410 of the Medicare Prescription Drug, Improvement, 
and Modernization Act of 2003 (MMA) amended the SNF consolidated billing law to 
specify that when a SNFs Part A resident receives the services of a physician (or another 
type of practitioner that the law identifies as being excluded from SNF consolidated 
billing) from a RHC or a FQHC, those services are not subject to CB merely by virtue of 
being furnished under the auspices of the RHC or FQHC.  Accordingly, under section 
410 of the MMA, services otherwise included within the scope of RHC and FQHC 
services that are also described in clause (ii) of section 1888(e)(2)(A) are excluded from 
consolidated billing, effective with services furnished on or after January 1, 2005.  Only 
this subset of RHC/FQHC services may be covered and paid separately when furnished 
to SNF residents during a covered Part A stay (see the regulations at 42 CFR  
411.15(p)(2)(xvii) and 405.2411(b)(2)).  Use TOBs 71x and 73x, respectively, to bill for 
these RHC/FQHC services.  See Pub. 100-02, Medicare Benefit Policy Manual, chapter 
13 for additional information on Part B coverage of RHC/FQHC services.  
 
20.1.1.2 - Hospitals Facility Charge in Connection with Clinic 
Services of a Physician 
(Rev. 3230, Issued: 04-03-15, Effective: 06-15-15, Implementation: 06-15-15) 
 
As noted above in section 20.1.1, physician services are excluded from Part A PPS 
payment and the requirement for consolidated billing.  When a beneficiary receives clinic 
services from a hospital-based physician, the physician in this situation would bill his or 
her own professional services directly to the A/B MAC (B) and would be reimbursed at 
the facility rate of the Medicare physician fee schedule - which does not include overhead 
expenses.  The hospital historically has submitted a separate Part B facility charge for 
the associated overhead expenses to its A/B MAC (A).  The hospitals facility charge 
does not involve a separate service (such as a diagnostic test) furnished in addition to the 
physicians professional service; rather, it represents solely the overhead expenses 
associated with furnishing the professional service itself.  Accordingly, hospitals bill for 
facility charges under the physician evaluation and management (E&M) codes in the 
range of 99201-99245 and G0463 (for hospitals paid under the Outpatient Prospective 
Payment System). 
  E&M codes, representing the hospitals facility charge for the overhead expenses 
associated with furnishing the professional service itself, are excluded from SNF CB.  
Effective for claims with dates of service on or after January 1, 2006, the CWF will 
bypass CB edits when billed with revenue code 0510 (clinic visit) with an E&M HCPCS 
code in the range of 99201-99245 and, effective January 1, 2014 with HCPCS code 
G0463. 
 
NOTE:  Unless otherwise excluded in one of the Five Major Categories for billing 
services to A/B MACs (A), physician services codes are to be billed to the A/B MAC (B) 
by the physician.  Facility charges associated with the physicians clinic visit must be 
reported as explained above. 
 
20.1.2 - Other Excluded Services Beyond the Scope of a SNF Part A 
Benefit 
(Rev. 4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19) 
 
The following services are not included in Part A PPS payment when furnished in a 
Medicare participating hospital or CAH and may be paid to the provider rendering them. 
 
This exception does not apply if the service is furnished in an ambulatory surgical center 
(ASC) or other independent (non-hospital) facility, because it specifically addresses those 
services that are so far beyond the normal scope of SNF care as to require the intensity of 
the hospital setting in order to be furnished safely and effectively.  In transmittals for Part 
A and B institutional billing providing the annual update list of HCPCS codes affected by 
SNF consolidated billing, such services are referred to as  Major Category I of SNF 
consolidated billing editing.  Note that of the types of services listed, only ambulatory 
surgeries are listed as inclusions, rather than exclusions, to consolidated billing. 
 
  Certain cardiac catheterizations; 
 
  Certain computerized axial tomography (CT) scans; 
 
  Certain magnetic resonance imaging (MRIs); 
 
  Certain ambulatory surgeries involving the use of a hospital operating room or 
comparable hospital facilities (i.e., the use of a gastrointestinal (GI) suite or 
endoscopy suite for the insertion of a percutaneous esophageal gastrostomy (PEG) 
tube).  For Part A inpatients, the professional portion of these services is billed by 
the rendering practitioner to the A/B MAC (B).  Any hospital outpatient charges 
are billed to the A/B MAC (A). 
 
  Certain radiation therapies; 
 
  Certain angiographies, and lymphatic and venous procedures; 
 
  Emergency services; and   
  Ambulance services when related to an excluded service within this list (see 20.3 
for ambulance transportation related to dialysis services). 
 
These relatively costly services are beyond the general scope of care in SNFs, and their 
receipt has the effect of temporarily suspending a beneficiarys status as a SNF resident 
for CB purposes with respect to such services.  Even though it may be medically 
appropriate for a beneficiary to be cared for in a SNF while receiving radiation therapy, 
the SNF is not responsible for paying for excluded radiation therapy itself when the 
beneficiary receives it as a hospital outpatient.  Similarly, angiography codes and codes 
for some lymphatic and venous procedures are considered beyond the general scope of 
services delivered by SNFs.  The hospital or CAH must bill the A/B MAC (A) for the 
services.  Excluded services provided to Medicare beneficiaries in swing beds subject to 
SNF PPS are to be billed on TOB 13x by the swing bed hospital (see 100.1). 
 
Services directly related to these services, defined as services billed for the same place of 
service and with the same line item date of service as the services listed below, are also 
excluded from SNF CB, with exceptions as listed below.  This language addresses 
excluding as directly related those items and services that are so closely associated with 
the excluded procedure that it would actually be impossible to perform the excluded 
procedure itself without them, such as the anesthesia for an excluded ambulatory surgical 
procedure under 20.1.2.1, or an otherwise bundled diagnostic test when needed to 
identify the cause of (and appropriate course of treatment for) a medical emergency under 
20.1.2.2. 
 
  Note that anesthesia, drugs incident to radiology and supplies will be bypassed by 
enforcement edits when billed with CT Scans, Cardiac Catheterizations, MRIs, 
Radiation Therapies, or Angiographies or surgeries. 
 
In general, bypasses also allow CT Scans, Cardiac Catheterization, MRI, Radiation 
Therapy, Angiography, and Outpatient Surgery HCPCS codes 0001T  0021T, 0024T  
0026T, or 10021 - 69990 (except those HCPCS codes listed in Major Category I. F.) to 
process and pay.  This includes all other revenue code lines on the incoming claim that 
have the same line item date of service (LIDOS). 
 
20.1.2.1 Outpatient Surgery and Related Procedures - INCLUSION 
(Rev. 3612, Issued: 09-16-16, Effective: 10-18-16, Implementation: 10-18-16) 
 
Inclusions, rather than exclusions, are given in this one case, because of the great number 
of surgical procedures that are excluded and can only be safely performed in a hospital 
operating room setting.  It is easier to automate edits around the much shorter list of 
inclusions under this category, representing minor procedures (such as debriding a 
mycotic toenail) that, while technically considered surgery, can nevertheless be safely 
performed at bedside in the SNF itself.  Additionally, this was the approach originally 
taken in the regulation to present this information. 
    Note that anesthesia, drugs, supplies and lab services will be bypassed by 
enforcement edits when billed with outpatient surgeries excluded from SNF CB.  
The bypass is implemented for these services when the line item date of service 
matches the line item date of service for the excluded surgery.  For revenue codes 
not requiring a line item date of service (i.e., pharmacy and supplies), the bypass 
will be implemented when no line item date of service is present. 
 
See 10.1 above for the link to where transmittals providing current lists of HCPCS 
codes used for Major Category I SNF consolidated billing editing can be found. 
 
20.1.2.2 - Emergency Services 
(Rev. 2573, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13) 
 
Emergency room services performed in hospitals, including CAHs, are excluded from 
SNF CB for beneficiaries that are in skilled Part A SNF stays.  Hospitals report 
emergency room (ER) services under the 045X (Emergency Room -x represents a 
varying third digit) revenue code with a line item date of service (LIDOS) indicating the 
date the patient entered the ER.  Services related to the ER encounter are also excluded 
from the SNF CB provision.  Emergency services are defined in the regulations at 42 
CFR 424.101 as . . . services that are necessary to prevent death or serious impairment 
of health and, because of the danger to life or health, require use of the most accessible 
hospital available and equipped to furnish those services.  In this context, false alarm 
situations may occasionally arise, in which the initial assessment of a beneficiarys 
condition as life-threatening subsequently proves to be unfounded (for example, where a 
patients chest pain and shortness of breath initially appear to be symptoms of a heart 
attack, but upon subsequent examination turn out to be merely a bad case of indigestion).  
Such situations still qualify for the emergency services exclusion from SNF CB as long 
as the initial symptoms provided a reasonable basis for assuming the onset of a medical 
emergency, even though this assumption ultimately was not borne out by subsequent 
events. 
 
Where services related to the ER encounter span more than one service date, hospitals 
must identify those services by appending a modifier ET (Emergency Services) to those 
line items.  The reporting of the ET modifier will alert CWF that these are related ER 
services performed on subsequent dates so the SNF CB edits in CWF will be bypassd. 
 
20.2 - Services Excluded from Part A PPS Payment and the 
Consolidated Billing Requirement on the Basis of Beneficiary 
Characteristics and Election 
(Rev. 2573, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13) 
 
SNF-516 
 
These services must be provided to specific beneficiaries, either: (A) End Stage Renal 
Disease (ESRD) beneficiaries, or (B) beneficiaries who have elected hospice, by specific 
licensed Medicare providers, and are excluded from SNF PPS and consolidated billing.  SNFs will not be paid for Category II.A services (dialysis, etc.) when the SNF is the 
place of service.  To receive Medicare payment, these services must be provided in a 
renal dialysis facility.  Hospices must also be the only type of provider billing hospice 
services. 
 
In transmittals for A/B MAC (A) billing that provide the annual update list of HCPCS 
codes affected by SNF consolidated billing, such services are referred to as Major 
Category II of SNF consolidated billing editing.  See 10.1 above for the link to where 
transmittals providing current lists of HCPCS codes used for edits for these types of 
services, known as Major Category II in SNF CB editing for A/B MACs (A). 
 
20.2.1  Dialysis and Dialysis Related Services to a Beneficiary With 
ESRD 
(Rev. 4001, Issued: 03-16-18, Effective: 06-19-18, Implementation: 06-19-18) 
 
Beneficiaries with ESRD may receive dialysis and dialysis related services from a 
hospital-based or free-standing RDF, or may receive home dialysis supplies and 
equipment from a supplier. The following services are excluded from SNF CB:  
 
  Certain dialysis services and supplies, including any related necessary ambulance 
services;  
 
  Home dialysis supplies and equipment, self-care home dialysis support services, 
and institutional dialysis services and supplies (other than those furnished or 
arranged for by the SNF itself) are not included in the SNF Part A PPS rate. These 
services may be billed separately to the A/B MAC (A) by the ESRD facility as 
appropriate; dialysis supplies and equipment may be billed to the Durable 
Medical Equipment Medicare Administrative Contractor (DME MAC) by the 
supplier; and  
 
  Erythropoiesis Stimulating Agents (ESAs) for certain dialysis patients, subject to 
methods and standards for its safe and effective use (see 42 CFR 494.80(a)(2) and 
(a)(4), 494.90(a)(4), and 494.100) may be billed by the RDF to the A/B MAC 
(A), or by the retail pharmacy to the DME MAC.  
 
By contrast, services that fall outside the scope of the Part B dialysis benefit do not 
qualify for the dialysis exclusion from SNF CB. Similarly, the SNF CB exclusion 
described above for ESAs does not encompass situations involving their use for a non-
dialysis purpose (such as ameliorating the side effects of chemotherapy treatments). The 
Part B dialysis benefit generally does not cover dialysis for those beneficiaries who do 
not have ESRD. However, an exception involves acute dialysis (HCPCS code G0491), 
for patients who do not have ESRD but require dialysis temporarily following an acute 
kidney injury (AKI) from a severe medical trauma (such as a drug overdose or a traffic 
accident). In contrast to maintenance dialysis for ESRD patients (who, in the absence of a 
kidney transplant, would remain on periodic dialysis indefinitely), there is an expectation  with acute dialysis that the patients own kidneys will eventually recover and resume 
their normal function. For services furnished on or after January 1, 2017, section 808(a) 
of Public Law 114-27 added acute dialysis to the scope of the Part B dialysis benefit, 
thereby effectively adding such services to the scope of the dialysis exclusion from SNF 
CB as well. 
 
20.2.1.1 - ESRD Services 
(Rev. 1252, Issued:  05-25-07; Effective:  10-01-06; Implementation:  08-27-07) 
 
Home dialysis supplies and equipment, self-care home dialysis support services, and 
institutional dialysis services and supplies (other than those that are furnished or arranged 
for by the SNF itself) are not included in the Part A PPS payment.  They may be billed 
separately to the A/B MAC (A) by the hospital or ESRD facility as appropriate. 
 
Specific coding is used to differentiate dialysis and related services that are excluded 
from SNF consolidated billing for ESRD beneficiaries in three cases: 
 
1. When the services are provided in a renal dialysis facility (RDF) (including 
ambulance services to and from the RDF if medically necessary); 
 
2. Home dialysis when the SNF constitutes the home of the beneficiary; and  
 
3. When ESA drugs are used for ESRD beneficiaries in conjunction with dialysis, and 
given by the RDF. 
 
Note that SNFs may not be paid for home dialysis supplies. 
 
20.2.1.2 - Coding Applicable to Dialysis Services Provided in a Renal 
Dialysis Facility (RDF) or Home 
(Rev. 1252, Issued:  05-25-07; Effective:  10-01-06; Implementation:  08-27-07) 
 
Providers should review Chapter 8, Outpatient ESRD Hospital, Independent Facility, and 
Physician/Supplier Claims, for coding applicable to services provided in a Renal Dialysis 
Facility. 
 
20.2.2 - Hospice Care for a Beneficiarys Terminal Illness 
(Rev.4163, Issued: 11-02-18, Effective: 12-04-18, Implementation: 12-04-18) 
 
Hospice care related to a beneficiarys terminal condition is excluded from SNF PPS and 
consolidated billing.  This is because section 1862(a)(18) of the Social Security Act (the 
Act) specifies that SNF consolidated billing applies to ...covered skilled nursing facility 
services described in section 1888(e)(2)(A)(i)...  Section 1888(e)(2)(A)(i) of the Act, in 
turn, defines covered skilled nursing facility services specifically in terms of (I) Part A 
SNF services, along with (II) those non-excluded services that (if not for the enactment of 
SNF consolidated billing) would be types of services ...for which payment may be 
made under Part B... (emphasis added). Hospice services would not fall within the  scope of clause (I) above because, unlike the diagnostic and therapeutic services 
covered under the Part A SNF benefit (see 1862(a)(1)(A) of the Act), hospice services 
are palliative (see 1862(a)(1)(C) of the Act). Hospice services also would not fall within 
the scope of clause (II) above, because this clause encompasses services that, if not for 
the enactment of consolidated billing, would be separately coverable under Part B, 
whereas the hospice benefit is a Part A benefit. Hospice services for terminal conditions 
are identified with the following types of bill: 81X or 82X.  Services unrelated to the 
beneficiarys terminal condition are designated by the presence of condition code 07.  
Such unrelated services are included in SNF PPS and consolidated billing. 
 
20.3 - Other Services Excluded from SNF PPS and Consolidated Billing 
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21) 
 
The following services may be billed separately under Part B by the rendering provider, 
supplier, or practitioner (other than the SNF that receives the Part A PPS payment) and 
paid to the entity that furnished the service.  These services may be provided by any 
Medicare provider licensed to provide them, other than the SNF that receives the Part A 
PPS payment, and are excluded from Part A PPS payment and the requirement for 
consolidated billing, and are referred to as Major Category III for consolidated billing 
edits applied to claims submitted to A/B MACs (A). 
 
  A medically necessary ambulance trip (other than a transfer to another 
SNF) that transports a beneficiary to the SNF for the initial admission or 
from the SNF following a final discharge, or that occurs pursuant to the 
offsite provision of Part B dialysis services (see section 20.3.1 for 
additional situations involving ambulance transportation); 
 
  Certain chemotherapy (that is, anti-cancer) drugs.  The chemotherapy 
exclusion applies solely to the particular chemotherapy codes designated 
under Major Category III.A of the SNF websites A/B MAC (A) Annual 
Update.  These same codes also appear on the list of exclusions in File 1 
of the SNF websites A/B MAC (B) Annual Update (though not displayed 
as a separate subcategory).  The excluded chemotherapy codes serve to 
identify those high-intensity chemotherapy drugs that are not typically 
administered in a SNF, are exceptionally expensive, or require special 
staff expertise to administer.  By contrast, chemotherapy drugs that are 
relatively inexpensive and are administered routinely in SNFs do not 
qualify for this exclusion and, thus, remain subject to SNF CB.  Further, 
this exclusion would not encompass any related items that, while 
commonly furnished in conjunction with chemotherapy, are not 
themselves inherently chemotherapeutic in nature (that is, they specifically 
address the side effects of the chemotherapy rather than actively fighting 
the cancer itself).  Examples of such chemotherapy-related drugs would 
include anti-emetics (anti-nausea drugs), as well as drugs that function as 
an adjunct to an anti-emetic, such as an anti-anxiety drug that helps to 
relieve anticipatory nausea.  Even when furnished in conjunction with a 
chemotherapy drug that is itself excluded (and, thus, separately payable  under Part B), these related drugs would remain subject to SNF CB.  
Similarly, if a drug designated by one of the excluded chemotherapy codes 
is prescribed for a use that is not actually associated with fighting cancer, 
it would no longer be considered an excluded chemotherapy drug in 
such an instance, because it is not being used for a chemotherapeutic 
purpose within the meaning of this exclusion. 
 
  Certain chemotherapy administration services.  The chemotherapy 
administration codes are included in SNF PPS payment for beneficiaries in 
a Part A stay when performed alone or with other surgery, but are 
excluded if they occur with the same line item date of service as an 
excluded chemotherapy agent.  A chemotherapy agent must also be billed 
when billing these services, and physician orders must exist to support the 
provision of chemotherapy; 
 
  Certain radioisotope services; 
 
  Certain customized prosthetic devices (see 10); 
 
  Effective for items and services furnished on or after October 1, 2021, 
certain blood clotting factors indicated for the treatment of hemophilia and 
other bleeding disorders; 
 
  The transportation costs of electrocardiogram equipment (HCPCS code 
R0076), but only with respect to those for electrocardiogram test services 
furnished during 1998; and 
 
  All services provided to risk-based MCO beneficiaries.  These 
beneficiaries may be identified with a label attached to their Medicare card 
and/or a separate health insurance card from an MCO indicating all 
services must be obtained or arranged through the MCO (as noted 
previously in 10, consolidated billing applies only to Medicare fee-for-
service beneficiaries). 
 
The HCPCS code ranges for chemotherapy, chemotherapy administration, radioisotopes, 
customized prosthetic devices, and blood clotting factors are set in statute.  The statute 
also gives the Secretary authority to make modifications in the particular codes that are 
designated for exclusion within each of these service categories.  See 10.1 above for the 
link to where transmittals providing current lists of HCPCS codes used for Major 
Category III SNF consolidated billing editing for A/B MACs (A) can be found. 
 
20.3.1 - Ambulance Services 
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21) 
 
The following ambulance transportation and related ambulance services for residents in a 
Part A stay are not included in the Part A PPS payment.  Except for specific exclusions,  consolidated billing includes those medically necessary ambulance trips that are 
furnished during the course of a covered Part A stay.  A/B MACs (A), (B), (HHH), and 
DME MACs are responsible for assuring that payment is made only for ambulance 
services that meet established coverage criteria. 
 
In most cases, ambulance trips are excluded from consolidated billing when resident 
status has ended.  The ambulance company then must bill the A/B MAC (A), (B), or 
(HHH), or DME MAC (as appropriate) directly for payment.  Listed below are a number 
of specific circumstances under which a beneficiary may receive ambulance services that 
are covered by Medicare, but excluded from consolidated billing. 
 
The following ambulance services may be billed as Part B services by the supplier in the 
following situations only. 
 
  The ambulance trip is to the SNF for admission (the second character 
(destination) of any ambulance HCPCS modifier is N (SNF) other than modifier 
QN, and the date of service is the same as the SNF 21X admission date.); 
 
  The ambulance trip is from the SNF after discharge, to the beneficiarys home 
(the first character (origin) of any HCPCS ambulance modifier is N (SNF), the 
second character (destination) of the HCPCS ambulance modifier is R 
(Residence), and date of ambulance service is the same date as the SNF through 
date).  Note: this includes beneficiaries discharged home to receive services from 
a Medicare-participating home health agency under a plan of care; 
 
  The ambulance trip is to or from a hospital based or nonhospital based ESRD 
facility (the first or second character (origin or destination) of the HCPCS 
ambulance modifier is N (SNF), and the other character of the HCPCS ambulance 
modifier is G (Hospital-based dialysis facility) or J (Non-hospital based dialysis 
facility)) for the purpose of receiving dialysis and related services excluded from 
consolidated billing. 
 
  The ambulance trip is from the SNF to a Medicare-participating hospital or a 
CAH for an inpatient admission (the first character (origin) of the HCPCS 
ambulance modifier is N (SNF), and the second character (destination) of the 
HCPCS modifier is H). 
 
  The ambulance trip follows a formal discharge or other departure from the SNF to 
any destination other than another SNF, and the beneficiary does not return to that 
or any other SNF before the following midnight; and 
 
  An ambulance trip that conveys a beneficiary to a hospital or CAH and back to 
the SNF, for the specific purpose of receiving emergency or other excluded 
services (see section 20.1.2 above for list of other excluded services).  As 
discussed in section 20.1.2, the receipt of these exceptionally intensive outpatient 
hospital services has the effect of temporarily suspending the beneficiarys status 
as an SNF resident for CB purposes with respect to those services; moreover,  once suspended in this manner, the beneficiarys resident status would not 
resume until he or she actually arrives back at the SNF.  Accordingly, the entire 
related ambulance roundtrip, both the outbound (SNF-to-hospital) portion and the 
return (hospital-to-SNF) portion, would be excluded from SNF CB and billed 
separately under Part B. 
 
The following ambulance services are included in SNF CB and may not be billed as Part 
B services to the A/B MAC (A), (B), or (HHH) when the beneficiary is in a Part A stay: 
 
  Transfers Between Two SNFs:  Under the regulations at 42 CFR 411.15(p)(3)(iv), 
the day of departure from SNF 1 is a covered Part A day (to which consolidated 
billing would apply) only if the beneficiarys admission to SNF 2 occurs before 
the following midnight (the first and second character of the ambulance modifier 
is N).  Patient Status is 03.  An ambulance trip that is medically necessary to 
effect this type of SNF-to-SNF transfer would be bundled back to SNF 1, as in 
this specific situation the beneficiary would continue to be considered a resident 
of SNF 1 for CB purposes up until the actual point of admission to SNF 2.  
However, it should be noted that in addition to the medical necessity criterion in 
the regulations at 42 CFR 409.27(c) pertaining specifically to ambulance 
transports under the SNF benefit (i.e., the patients medical condition is such that 
transportation by any means other than ambulance would be contraindicated), 
coverage in this context also involves the underlying requirement of being 
reasonable and necessary for diagnosing or treating the patients condition.  For 
example, a SNF-to-SNF transfer would be considered reasonable and necessary in 
a situation where needed care is unavailable at the originating SNF, thus 
necessitating a transfer to the receiving SNF in order to obtain that care.  By 
contrast, a SNF-to-SNF transfer that is prompted by non-medical considerations 
(such as the patients preference to be placed in the receiving SNF) is not 
considered reasonable and necessary for diagnosing or treating the patients 
condition and, thus, would not be bundled back to the originating SNF. 
 
  Ambulance transports to or from a diagnostic or therapeutic site other than a 
hospital or renal dialysis facility (e.g., an independent diagnostic testing facility 
(IDTF), cancer treatment center, radiation therapy center, wound care center, 
etc.).  The ambulance transport is included in the SNF PPS rate if the first or 
second character (origin or destination) of any HCPCS code ambulance modifier 
is D (diagnostic or therapeutic site other than P or H), and the other 
modifier (origin or destination) is N (SNF).  The first SNF is responsible for 
billing the services to the A/B MAC (A). 
 
  An SNF residents ambulance roundtrip to a physicians office (first or second 
character (origin or destination) of any HCPCS code ambulance modifier is P 
(physicians office), and the other modifier (origin or destination) is N (SNF)) 
is subject to SNF CB and would remain the responsibility of the SNF, because 
even though the physicians services are themselves excluded from SNF CB, this 
exclusion does not affect the beneficiarys overall status as an SNF resident for 
CB purposes.  Further, while a physicians office is not normally a covered  destination under the separate Part B ambulance benefit, the SNF benefits Part 
A coverage of ambulance transportation under the regulations at 42 CFR 
409.27(c) incorporates only the Part B ambulance benefits general medical 
necessity requirement at 42 CFR 410.40(e)(1), and not any of the latter benefits 
more detailed coverage restrictions regarding destinations. 
 
See chapter 15 for additional information on Part B coverage of Ambulance Services. 
 
In contrast to the ambulance coverage described above, Medicare simply does not 
provide any coverage at all under Part A or Part B for any non-ambulance forms of 
transportation, such as ambulette, wheelchair van, or litter van.  Further, as noted 
previously, in order for the Part A SNF benefit to cover transportation via ambulance, the 
regulations at 42 CFR 409.27(c) specify that the ambulance transportation must be 
medically necessary, that is, the patients condition is such that transportation by any 
means other than ambulance would be medically contraindicated. 
 
This means that in a situation where it is medically feasible to transport an SNF resident 
by some means other than an ambulance, for example, via wheelchair van, the wheelchair 
van would not be covered (because Medicare does not cover any non-ambulance forms of 
transportation), and an ambulance also would not be covered (because the use of an 
ambulance in such a situation would not be medically necessary).  With respect to 
noncovered services for which a resident may be financially liable, the SNF is required 
under the regulations at 42 CFR 483.10(g)(18) to . . . inform each resident before, or at 
the time of admission, and periodically during the residents stay, of services available in 
the facility and of charges for those services, including any charges for services not 
covered under Medicare/Medicaid or by the facilitys per diem rate. 
 
20.4 - Screening and Preventive Services 
(Rev.4163, Issued: 11-02-18, Effective: 12-04-18, Implementation: 12-04-18) 
 
The Part A SNF benefit is limited to services that are reasonable and necessary to 
diagnose or treat a condition that has already manifested itself.  Accordingly, this 
benefit does not encompass screening services (which serve to check an at-risk individual 
for the possible presence of a specific latent condition, before it manifests any overt 
symptoms to diagnose or treat) or preventive services (which are aimed at warding off the 
occurrence of a particular condition altogether rather than diagnosing or treating it once it 
occurs).  Coverage of screening and preventive services (e.g., screening mammographies, 
pneumococcal pneumonia vaccine, influenza vaccine, hepatitis B vaccine) is a separate 
Part B inpatient benefit when rendered to beneficiaries in a covered Part A stay and is 
paid outside of the Part A payment rate. For this reason, screening and preventive 
services must not be included on the global Part A bill.  However, screening and 
preventive services remain subject to consolidated billing and, thus, must be billed 
separately by the SNF under Part B. 
 
Accordingly, even though the SNF itself must bill for these services, it submits a separate 
Part B inpatient bill for them rather than including them on its global Part A bill.  
Screening and preventive services must be billed with a 22X type of bill. Swing Bed  providers must use TOB 12x for eligible beneficiaries in a Part A SNF level of care.  
NOTE:  For beneficiaries residing in the Medicare non-certified area of the facility, these 
services should be billed on a 23x type of bill.  In transmittals for A/B MAC (A) billing 
providing the annual update list of HCPCS codes affected by SNF consolidated billing, 
such services are referred to as Major Category IV.  See 10.1 above for the link to 
where transmittals providing current lists of HCPCS codes used for Major Category IV 
can be found. 
 
There are certain limited circumstances in which a vaccine would no longer be 
considered preventive in nature, and this can affect how the vaccine is covered.  For 
example, while a booster shot of tetanus vaccine would be considered preventive if 
administered routinely in accordance with a recommended schedule, it would not be 
considered preventive when administered in response to an actual exposure to the disease 
(such as an animal bite, or a scratch on a rusty nail). In the latter situation, such a vaccine 
furnished to an SNFs Part A resident would be considered therapeutic rather than 
preventive in nature, as its use is reasonable and necessary for treating an existing 
condition. 
 
In terms of billing for an SNFs Part A resident, a vaccine that is administered for 
therapeutic rather than preventive purposes would be included on the SNFs global Part 
A bill for the residents covered stay.  Alternatively, if a vaccine is preventive in nature 
and is one of the three types of vaccines (i.e., pneumococcal pneumonia, hepatitis B, or 
influenza virus) for which a Part B benefit category exists (see 50.4.4.2 of the Medicare 
Benefit Policy Manual, Chapter 15), then the SNF would submit a separate Part B bill for 
the vaccine.  (Under section 1888(e)(9) of the Social Security Act (the Act) and the 
implementing regulations at 42 CFR 413.1(g)(2)(ii), payment for an SNFs Part B 
services generally is made in accordance with the applicable fee schedule for the type of 
service being billed (see the Medicare Claims Processing Manual, Chapter 7, 10.5).  
However, when these three types of vaccines are furnished in the SNF setting, Part B 
makes payment in accordance with the applicable instructions contained in the Medicare 
Claims Processing Manual, Chapter 7, 80.1, and Chapter 18, 10.2.2.1.) 
 
If the resident receives a type of vaccine that is preventive in nature but for which no Part 
B benefit category exists (e.g., diphtheria), then the vaccine would not be covered under 
either Parts A or B and, as a consequence, would become coverable under the Part D drug 
benefit.  This is because priority of payment between the various parts of the Medicare law 
basically proceeds in alphabetical order:  Part A is primary to Part B (see section 1833(d) of 
the Act), and both Parts A and B are primary to Part D (see section 1860D-2(e)(2)(B) of the 
Act). 
 
Further, it is worth noting that unlike preventive services covered under Part B, those 
preventive vaccines covered under Part D are not subject to SNF CB, even when 
furnished to an SNFs Part A resident. This is because section 1862(a)(18) of the Act 
specifies that SNF CB applies to . . . covered skilled nursing facility services described 
in section 1888(e)(2)(A)(i) . . . . Section 1888(e)(2)(A)(i) of the Act, in turn, defines 
covered skilled nursing facility services specifically in terms of (I) Part A SNF 
services, along with (II) those non-excluded services that (if not for the enactment of SNF  CB) would be types of services . . . for which payment may be made under Part B . . . 
(emphasis added).  Preventive and screening services as a class would not fall within the 
scope of clause (I) above because, as discussed previously, the diagnostic and 
therapeutic services covered under the Part A SNF benefit (see 1862(a)(1)(A) of the 
Act) do not encompass preventive services (see 1862(a)(1)(B) of the Act) or screening 
services (see 1862(a)(1)(F), (G), (H), (L), (M), and (N) of the Act). Similarly, those 
Part D preventive drugs (such as preventive vaccines) for which no Part B benefit 
category exists would not fall within the scope of clause (II) above, because this clause 
encompasses services that, if not for the enactment of CB, would be separately coverable 
under Part B. 
 
Formerly, bone mass measurement (screening) was listed as a preventive service 
excluded from SNF consolidated billing.  This was incorrect.  Such services are 
diagnostic, not screening, procedures, and therefore are bundled into SNF PPS payment 
and subject to consolidated billing. 
 
20.5 - Therapy Services 
(Rev. 2573, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13) 
 
Therapy services are edited as inclusions, rather than exclusions, to consolidated billing.  
Physical therapy, speech-language pathology services, and occupational therapy are 
bundled into the SNFs global per diem payment for a residents covered Part A stay. 
They are also subject to the SNF Part B consolidated billing requirement (for services 
furnished to SNF residents during noncovered stays) and must be billed by the SNF 
alone for its Part B residents on a 22x type of bill. 
 
As noted in section 10.3 of this chapter, therapy services furnished to SNF residents 
remain subject to consolidated billing even when performed by a type of practitioner, 
such as a physician, whose services would otherwise be excluded (see section 
1888(e)(2)(A)(ii) of the Social Security Act and the regulations at 42 CFR 
411.15(p)(1)(i)).  Further, while most services either clearly fall within the category of 
therapy or clearly fall outside of it,  there are a few services (such as certain debridement 
codes) which, based on the specific type of practitioner involved, are sometimes 
considered therapy services and other times not.  However, because the consolidated 
billing provision focuses on the nature of the therapy service itself (rather than the type of 
practitioner who happens to be performing it), these sometimes therapy codes are 
always considered therapy services in the specific context of SNF consolidated 
billing.  This means that a practitioner who furnishes such a service to an SNF resident 
must always look to the SNF itself (rather than to Part B) for payment. 
 
SNF residents that fall below a Medicare skilled level of care may be moved out of the 
SNF or certified distinct part unit (DPU) to the Medicare non-certified area of the facility.  
In doing so, the beneficiary is no longer subject to the SNF consolidated billing rule and 
therapy services may be billed directly to Medicare by the provider rendering the service 
or if billed by the SNF should be submitted on a 23x type of bill.  If the entire facility 
qualifies as a Medicare-certified SNF, all Part B therapies must continue to be billed by 
the SNF on a 22x type of bill.  The CWF SNF CB therapy edit will be bypassed for 22x  bill types that contain therapy services when those line item dates of service fall within a 
non-covered period reported on an inpatient 21x bill type.  For additional instructions, see 
Chapter 7, SNF Part B Billing, section 10.1.  In transmittals for A/B MAC (A) billing 
providing the annual update list of HCPCS codes affected by SNF consolidated billing, 
such services are referred to as Major Category V of SNF consolidated billing.  See 
section 10.1 above for the link to where transmittals providing current lists of HCPCS 
codes used for Major Category V can be found. 
 
20.6 - SNF CB Annual Update Process for A/B MACs (A) 
(Rev. 3230, Issued: 04-03-15, Effective: 06-15-15, Implementation: 06-15-15) 
 
Barring any delay in the Medicare Physician Fee Schedule, CMS will provide the new 
Annual Update code file to CWF by November 1. Should this date change, CWF will be 
notified through the appropriate mechanism. All future updates will be submitted via a 
Recurring Update Notification form. These Recurring Update Notifications also describe 
how the changes will be implemented. 
 
The CWF contractor shall compare the new code list for Major Categories I through V to 
the codes in the current edits. Codes that appear on the new list, but not in the current 
edit, shall be added to the edit. 
 
CMS will make a determination as to which codes should be deleted from which edits. 
This mechanism will allow for any changes in professional component/technical 
component designations to be correctly coded for edits and for deleted codes and codes 
no longer valid for Medicare purposes as of the end of the calendar year, to continue to 
pay correctly for prior dates of service. 
 
CMS will respond to the list provided by the CWF contractor and provide the 
determination on the codes to the CWF contractor. 
 
The CWF contractor will delete codes from the edits per the CMS determination. 
 
A/B MACs (A), a term used to indicate both Part A and Part B institutional services, shall 
continue to respond to rejects and unsolicited responses received from CWF per current 
methodology.  A/B MACs (A) shall reopen and reprocess any claims brought to their 
attention for services that prior to this update were mistakenly considered to be subject to 
consolidated billing and therefore, not separately payable.  A/B MACs (A) need not 
search claims history to identify these claims.  Prior to January 1 of each year, a new 
code file will be posted to the CMS Web site at: 
http://www.cms.hhs.gov/SNFConsolidatedBilling/.  Should this date change, A/B MACs 
(A) will be notified through the appropriate mechanism. 
 
Coding changes throughout the year may also be made as necessary through a quarterly 
update process. 
 
As soon as the new code file is posted to the CMS Web site, through their Web sites and 
list serves, A/B MACs (A) shall notify providers of the availability of the new file.   
 
30 - Billing SNF PPS Services 
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21) 
 
SNFs and hospital swing bed providers are required to report inpatient Part A PPS billing 
data as follows.  Refer to the Medicare Claims Processing Manual, Chapter 25, 
Completing and Processing the Form CMS-1450 Data Set, for a description of claim 
data elements. 
 
  In addition to the required fields identified in Chapter 25, SNFs must also report 
occurrence span code 70 to indicate the dates of a qualifying hospital stay of at 
least three consecutive days which qualifies the beneficiary for SNF services. 
 
  Separate bills are required for each Federal fiscal year for admissions that span 
the annual update effective date (October 1). 
 
  Use Type of Bill 21X for SNF inpatient services or 18X for hospital swing bed 
services. 
 
  Revenue Code 0022.  This code indicates that this claim is being paid under the 
SNF PPS.  This revenue code can appear on a claim as often as necessary to 
indicate different HIPPS Rate Code(s) and assessment periods. 
 
  Effective for claims with dates of service on or after January, 1 2011, there must 
be an occurrence code 50 (assessment date) for each assessment period 
represented on the claim with revenue code 0022.  The date of service reported 
with occurrence code 50 must contain the ARD.  An occurrence code 50 is not 
required with default HIPPS code AAAxx (where xx equals varying digits) or 
ZZZZZ October 1, 2019 and after.  In addition, for OMRA related AIs 05, 06, 0A, 
0B, 0C, 12, 13, 14, 15, 16, 17, 1A, 1B, 1C, 24, 25, 26, 2A, 2B, 2C, 34, 35, 36, 3A, 
3B, 3C, 44, 45, 46, 4A, 4B, 4C, 54, 55, 56, 5A, 5B, 5C where 2 HIPPS may be 
produced by one assessment, providers need only report one occurrence code 50 
to cover both HIPPS codes.  As of October 1, 2019, SNF PDPM changes are 
effective (see 120ff.). 
 
  HCPCS/Rates field must contain a 5-digit HIPPS Code.  The first three 
positions of the code contain the RUG group and the last two positions of the 
code contain a 2-digit assessment indicator (AI) code.  See Chapter 6 of the MDS 
RAI manual for valid RUG codes and AI codes.  As of October 1, 2019, SNF 
PDPM changes are effective (see 120ff.). 
 
  SNF and SB PPS providers must bill the HIPPS codes on the claim form in the 
order in which the beneficiary received that level of care.   
  Service Units must contain the number of covered days for each HIPPS rate code. 
 
NOTE: Fiscal Intermediary Shared System (FISS) requirement: 
 
The sum of all covered units reported on all revenue code 0022 lines 
should be equal to the covered days field less the number of days 
reported in an OSC 77.  (NOTE: The covered units field is utilized in 
FISS and has no mapping to the 837 or paper claim). 
 
  Total Charges should be zero for revenue code 0022. 
 
  When a HIPPS rate code of RUAxx, RUBxx, RUCxx, RULxx and/or RUXxx is 
present, a minimum of two rehabilitation therapy ancillary codes are required 
(revenue code 042x and/or, 043x and/or, 044x).  When a HIPPS rate code of 
RHAxx, RHBxx, RHCxx, RHLxx, RHXxx, RLAxx, RLBxx, RLXxx, RMAxx, 
RMBxx, RMCxx, RMLxx, RMXxx, RVAxx, RVBxx, RVCxx, RVLxx, and/or 
RVXxx is present, a minimum of one rehabilitation therapy ancillary revenue 
code is required (revenue code 042x, 043x, or 044x.  Bills that are missing 
required rehabilitation therapy ancillary revenue codes are to be returned to the 
SNF for resubmission.  As of October 1, 2019, SNF PDPM changes are effective 
(see 120ff.). 
 
  The accommodation revenue code 018x, leave of absence is reported when the 
beneficiary is on a leave of absence and is not present at the midnight census 
taking time. 
 
  Principal Diagnosis Code - SNFs enter the ICD-CM code for the principal 
diagnosis in the appropriate form locator.  The code must be reported according to 
Official ICD-CM Guidelines for Coding and Reporting, as required by the Health 
Insurance Portability and Accountability Act (HIPAA), including any applicable 
guidelines regarding the use of V codes for ICD-9.  The code must be the full 
ICD-CM diagnosis code, including all five digits (for ICD-9) or all seven digits 
(for ICD-10) where applicable. 
 
  Other Diagnosis Codes Required - The SNF enters the full ICD-CM codes 
for up to eight additional conditions in the appropriate form locator.  
Medicare does not have any additional requirements regarding the 
reporting or sequence of the codes beyond those contained in the ICD-CM 
guidelines. 
 
30.1 - Health Insurance Prospective Payment System (HIPPS) Rate 
Code 
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)   
The HIPPS rate code consists of the three-character resource utilization group (RUG) 
code that is obtained from the Grouper software program followed by a 2-digit 
assessment indicator (AI) that specifies the type of assessment associated with the RUG 
code obtained from the Grouper. Providers may access the Resident Assessment 
Instrument (RAI) manual located at the following link for assessment-related issues: 
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/NursingHomeQualityInits/index.html. 
 
SNFs must use the version of the Grouper software program identified by CMS for 
national PPS as described in the Federal Register for that year.  The Grouper translates 
the data in the Long Term Care Resident Instrument into a case-mix group and assigns 
the correct RUG code. Effective for dates of service on or after October 1, 2010, the 
Grouper will automatically assign the 2-digit AI. 
 
Providers may access the following link for HIPPS code information: 
http://www.cms.hhs.gov/ProspMedicareFeeSvcPmtGen/02_HIPPSCodes.asp#TopOfPage  
 
The above link includes documents that contain the complete list of RUG codes and AIs 
billed for Part A SNF stays.  Definitions and usage of each code are included.  In 
addition, a master file of all valid/termed HIPPS codes is provided. 
 
The HIPPS rate code that appears on the claim must match the assessment that has been 
transmitted and accepted by the State in which the facility operates.  The SNF may bill the 
program only after: 
 
  An assessment has been completed and submitted to the State RAI Database; 
 
  A Final Validation Report indicating that the assessment has been accepted by the 
state; and 
 
  The covered day has actually been used. 
 
SNFs that submit claims that have not completed this process will not be paid.  It is 
important to remember that the record will be accepted into the State RAI database, even 
if the calculated RUG code differs from the submitted values.  The error will be flagged 
on the final validation report by issuing a warning message and listing the correct RUG 
code.  When such discrepancies occur, the RUG code reported on the Final Validation 
Report shall be used for billing purposes.  As of October 1, 2019, SNF PDPM changes 
are effective (see 120ff.). 
 
 
30.2  Coding PPS Bills for Ancillary Services 
(Rev. 3230, Issued: 04-03-15, Effective: 06-15-15, Implementation: 06-15-15) 
 
When coding PPS bills for ancillary services associated with a Part A inpatient stay, the 
traditional revenue codes will continue to be shown, e.g., 0250 - Pharmacy, 042x -  Physical Therapy, in conjunction with the appropriate entries in Service Units and Total 
Charges. 
 
  SNFs are required to report the number of units based on the procedure or service. 
 
  For therapy services, that is revenue codes 042x, 043x, and 044x, units represent 
the number of calendar days of therapy provided.  For example, if the beneficiary 
received physical therapy, occupational therapy or speech-language pathology on 
May 1, that would be considered one calendar day and would be billed as one 
unit. 
 
  SNFs are required to report the actual charge for each line item, in Total Charges. 
 
30.3  Adjustment Requests 
(Rev. 3230, Issued: 04-03-15, Effective: 06-15-15, Implementation: 06-15-15) 
 
Adjustment requests based on corrected assessments must be submitted within 120 days 
of the service through date.  The through date will be used to calculate the period 
during which adjustment requests may be submitted based on corrected RAI assessments.  
The through date indicates the last day of the billing period for which the HIPPS code 
is billed.  Adjustment requests based on corrected assessments must be submitted within 
120 days of the through date on the bill.  For HIPPS changes resulting from an MDS 
correction, providers must append a condition code D2 on their adjustment claim.  An 
edit is in place to limit the time for submitting this type of adjustment request to 120 days 
from the service through date. 
 
The CMS expects that most HIPPS code corrections will be made during the course of 
the beneficiarys Medicare Part A stay.  Therefore, providers that routinely submit 
corrections after the beneficiarys Part A stay has ended may be subject to focused 
medical review. 
 
Adjustment requests to change a HIPPS code may not be submitted for any claim that has 
already been medically reviewed, such claims are identified in the FISS system by an 
indicator on the claim record.  This applies whether or not the medical review was 
performed either pre- or post-payment.  All adjustment requests submitted are subject to 
medical review.  Information regarding medical review is located in the Medicare 
Program Integrity Manual. 
 
30.4 - SNF PPS Pricer Software 
(Rev. 3230, Issued: 04-03-15, Effective: 06-15-15, Implementation: 06-15-15) 
 
The Balanced Budget Act (BBA) of 1997 (Public Law 105-33) mandated the 
implementation of a per diem prospective payment system (PPS) for skilled nursing 
facilities (SNFs), covering all costs (routine, ancillary, and capital) of covered SNF 
services furnished to beneficiaries under Part A of the Medicare program. 
  Effective for cost reporting periods beginning on or after July 1, 1998, all skilled nursing 
services billed on TOB 21x will be paid based on calculations made by the SNF Pricer. 
The SNF Pricer operates as a module within CMS claims processing systems.  The SNF 
Pricer makes all payment calculations applicable under SNF PPS.  Medicare claims 
processing systems must send an input record for each HIPPS code reported on the claim 
to Pricer and Pricer will return an output record to the shared systems.  The Pricer is 
available electronically to the shared systems and is updated at least annually. A PC 
version of the SNF Pricer Program can be found at: 
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PCPricer/SNF.html 
 
The following describes the elements of SNF PPS claims that are used in the SNF PPS 
Pricer and the logic that is used to make payment determinations.  No part of the Pricer 
logic is required to be incorporated into a SNFs billing system in order to bill Medicare. 
The following is presented for A/B MACs (A) and as information for the SNFs, in order 
to help SNFs understand their SNF PPS payments and how they are determined. 
 
30.4.1 - Input/Output Record Layout                                                      
(Rev. 11109, Issued: 11-04-21 Effective:10-01-22, Implementation:01-03-22) 
 
The SNF Pricer input/output file will be 300 bytes in length.  The required data and 
format are shown below. 
 
File  Format  Title  Description 
Position 
1-4  X(4)  MSA  Input item: The metropolitan 
statistical area (MSA) code.  
Medicare claims processing systems 
pull this code from field 13 of the 
provider specific file. 
5-9  X(5)  CBSA  Input item: Core-Based Statistical 
Area  
10  X  SPEC-WI-IND  Input item (if applicable) :Special 
Wage Index Indicator 
Valid Values: Y (yes) or N (no) 
11-16  X(6)  SPEC-WI  Input item (if applicable): Special 
Wage Index 
17-21  X(5)  HIPPS-CODE  Input Item: Health Insurance 
Prospective Payment System Code  
Medicare claims processing systems 
must copy the HIPPS code reported  File  Format  Title  Description 
Position 
by the provider on each 0022 revenue 
code line 
22-29  9(8)  FROM-DATE  Input item: The statement covers 
period from date, copied from the 
claim form. Date format must be 
CCYYMMDD. 
30-37  9(8)  THRU-DATE  Input item: The statement covers 
period through date, copied from 
the claim form.  Date format must be 
CCYYMMDD. 
38  X  QRP-IND  Input Item-Effective January 1, 2022 
field renamed QRP-IND from FED-
PPS-BLEND. 
Input Item: Effective October 1, 2017, 
MACs shall populate the FED PPS 
BLEND IND field in the PSF with a 
"1" to indicate the SNF did not meet the 
quality reporting requirements.- 
39-45  9(05)V9(02)  SNF-FACILITY  Input item: Rate based on each SNFs 
RATE  historical costs (from (from A/B 
MAC (A) audited cost reports) 
including exception payments. 
NOTE:  All facilities have been paid 
at the full federal rate since FY 2002. 
46-52  X(7)  SNF-PRIN-DIAG- Input item: The principle diagnosis 
CODE  code, copied from the claim form.  
Must be three to seven positions left 
justified with no decimal points. 
53-59  X(7)  SNF-OTHER- Input item: Additional Diagnosis 
DIAG-CODE2  Code, copied from the claim form, if 
present, must be three to seven 
positions left justified with no 
decimal points. 
60-220  Defined  Additional  Input item: Up to twenty-three 
above  Diagnosis data  additional diagnosis codes accepted 
from claim. Copied from the claim 
form.  Must be three to seven  File  Format  Title  Description 
Position 
positions left justified with no 
decimal points. 
Output Item: The Calculated 
221-228  9(06)V9(02)  SNF-PAYMENT 
TOTAL amount received by the 
RATE 
SNF based on the days received.  
Effective FY 2018, this amount 
reflects VBP adjustment.  
NOTE: Effective October 1, 2019, 
the previously calculated RUG per 
diem rate is replaced by the PDPM 
Calculated TOTAL amount 
received by the SNF.  
 
229-230  9(2)  SNF-RTC  Output item: A return code set by 
Pricer to define the payment 
circumstances of the claim or an error 
in input data. 
Payment return code: 
00  HIPPS rate returned 
Error return codes: 
20  INVALID RATE 
COMPONENT  
30 Bad CBSA code 
40 Thru date < July 1, 1998 or 
Invalid 
50  Invalid federal blend for that 
Year-NO LONGER IN USE 
60  Invalid federal blend-NO 
LONGER IN USE 
61  Federal blend = 0 and SNF 
Thru date < January 1, 2000-NO 
LONGER IN USE 
 70     Invalid VBP Multiplier- 
       80     SNF-PDPM-UNITS =       
ZERO 
       90      INVALID HIPPS CODE 
       01     CURRENT-DAYS > 100   File  Format  Title  Description 
Position 
231-242  S9V9(11)  VBP-MULTIPLIER  Input item: Medicare systems move 
this information from field 52 of the 
provider specific file.  
Output item: The total SNF VBP 
243-250  S9(06)V9(02)  VBP-PAY-DIFF 
adjustment amount, determined by 
subtracting the SNF VBP adjustment 
total payment from the SNF PPS 
payment that would otherwise apply 
to the line. Added to the claim as a 
value code QV amount.  
NOTE: Effective October 1, 2019, 
the previously calculated VBP 
difference per day is replaced by the 
TOTAL VBP difference amount.  
251-252   9(02)   SNF-PDPM-UNITS   Input item: The number of service 
units reported by the SNF on the 
revenue code 0022 line that is being 
priced.  
253-255   9(03)   SNF-PDPM- Input item: When pricing the first 
PRIOR-DAYS   revenue code 0022 line on a claim, 
this is the number of prior SNF days 
identified by FISS from claims 
history. On later dated revenue code 
0022 lines, this is the days from 
claims history plus any units from any 
earlier dated.  
256-300   X(45)   FILLER   Blank  
 
Input records on claims must include all input items. Output records will contain all input 
and output items. 
The Medicare claims processing systems will move the following Pricer output items to 
the claim record. The return code will be placed in the claim header. The SNF-
PAYMENT-RATE amount for each HIPPS code will be placed in the rate field of the 
appropriate revenue code 0022 line.  The Medicare claims processing systems will 
multiply the rate on each 0022 line by the number of units that correspond to each line.  
The system will sum all 0022 lines and place this amount in the Provider 
Reimbursement field minus any coinsurance due from the patient.  For claims with dates 
of service on or after July 1, 2002, Pricer will compute payment only where the SNF-
RTC is 00. 
  30.4.2  SNF PPS Rate Components 
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21) 
 
The SNF PPS rate for each RUG group consists of 3 components:  a nursing component, 
a therapy component and a non-case-mix adjusted component.  The following describes 
the rate components used for SNF PPS: 
 
  The nursing per diem amount is a standard amount which includes direct 
nursing care and the cost of non-therapy ancillary services required by 
Medicare beneficiaries. 
 
  The nursing index is based on the amount of staff time, weighted by salary 
levels, associated with each RUG group.  This index represents the 
amount of nursing time associated with caring for beneficiaries who 
qualify for the group. 
 
The nursing per diem amount is case-mix adjusted by applying the nursing index.  The 
result is the nursing component for that RUG group. 
 
  The therapy per diem amount is a standard amount which includes 
physical, occupational, and speech-language therapy services provided to 
beneficiaries in a Part A stay.  Payment varies based on the actual therapy 
resource minutes received by the beneficiary and reported on the MDS; 
 
  The therapy index is based on the amount of staff time, weighted by 
salary levels, associated with each RUG group.  This index represents the 
amount of rehabilitation treatment time associated with caring for 
beneficiaries who qualify for the group. 
 
If the RUG group is in the Rehabilitation plus Extensive Services or Rehabilitation 
category, the therapy per diem amount is case-mix adjusted by applying the therapy 
index.  The result is the therapy component for that Rehabilitation RUG group. 
 
  The non-case-mix therapy component is a standard amount to cover the 
cost of therapy assessments of beneficiaries who were determined not to 
need continued therapy services. 
 
If the RUG group is not in the Rehabilitation plus Extensive Services or Rehabilitation 
category, this payment is added to the rate as therapy component for that RUG group. 
 
  The non-case-mix component is also a standard amount added to the rate 
for each RUG group to cover administrative and capital-related costs. 
 
This standard amount is added to all RUG groups. 
 
As of October 1, 2019, SNF PDPM changes are effective (see 120ff.).  30.4.3 - Decision Logic Used by the Pricer on Claims 
(Rev. 4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19) 
 
A. Claims for services furnished prior to October 1, 2019, under RUG-
IV 
 
The SNF Pricer shall calculate the rate for each line item with revenue code 0022 on a 
SNF claim.  The SNF Pricer shall determine the rate using the following information: 
 
- HIPPS-CODE on line item 0022; 
-CBSA 
- Per diem amounts defined within the Pricers as types of rate based on the 
statement covers THRU-DATE: 
  Inpatient rate = Nursing case mix component 
  General service rate = Non-case-mix component 
  Therapy rate = Therapy non-case mix component 
  Rehabilitation rate = Therapy case-mix component 
- Labor and non labor percentages based on the statement covers THRU-
DATE; 
- Wage index, SNF-FED BLEND year, and SNF-FACILITY RATE based on 
the statement covers THRU_DATE 
- Rate adjustments applicable to the specific RUG code; 
- Nursing index based on the RUG code; 
- Therapy index based on the rehabilitation RUG code; 
 
On input records with TOB 21x (that is, all provider submitted claims and provider or 
A/B MAC (A) initiated adjustments), Pricer will perform the following calculations in 
numbered order for each RUG code: 
 
(1)  Multiply the applicable urban or rural inpatient rate depending on CBSA by the 
nursing index; 
 
(2)  Multiply the applicable urban or rural rehab rate by the therapy index, add to 
(1); 
 
(3)  For the top 23 RUG categories, add the general service rate to the sum of (1) 
and (2) for the (non-wage-adjusted) total PPS rate and proceed to step (4); OR 
for the lower 43 RUG categories, add the general service rate to the therapy rate 
to the sum of (1) and (2) for the (non-wage- adjusted) total PPS rate and proceed 
to step (4); 
 
(4)  Multiply the sum of (3) by the labor percentage then multiply the product by the 
applicable wage index and round; 
 
(5)  Multiply the sum of (3) by the non- labor percentage and round; 
  (6)  Add the product of (5) to the non-labor product in (4) for the (wage-adjusted) 
total PPS rate. 
 
Conditional Steps completed if applicable after (6): 
 
(6a)  If ICD-10-CM diagnosis code B20 (or, for services furnished prior to October 1, 
2015, ICD-9-CM diagnosis code 042) is present, multiply (6) by 2.28. 
 
B. Claims for services furnished on or after October 1, 2019, under the 
SNF PDPM 
 
The SNF PDPM Pricer shall calculate the rate for each line item with revenue code 0022 
on a SNF claim.  The SNF PDPM Pricer shall determine the rate using the following 
information: 
SNF PRICER uses the REGION IND, HIPPS CODE, QRP-IND & AIDS ADD-ON-IND 
to CALCULATE THE HCPPS RATES.                       
  
1.    CBSA   
a.    URBAN = 5 numeric characters 
b.    RURAL = 3 spaces & 2 digit state code 
c.    SPECIAL = APPLY SPECIAL WAGE INDEX "IN LIEU" OF CBSA 
WAGE INDEX 
                                                                 i.    SPECIAL = SNF-SPEC-WI-IND = '1' ON 
SNF-INPUT-RECORD and SNF-SPEC-WI-X = 5 
numeric characters 
                                                                ii.    CBSA-WIR-EFFDATE = '20051001'. 
  
2.    HIPPS CODE - 5 CHARACTERS = 4 alpha/1 numeric character. [on line 
item 0022] 
Evaluate each of the 1st four characters to select component rates: 
a.    Character # 1 = component rate for Physical Therapy (PT) & 
Occupational Therapy (OT). There are 16 PDPM Groups A thru 
P.  
b.    Character # 2 = component rate for Speech Language 
Pathology  (SLP). There are 12 PDPM Groups A thru L. 
c.    Character # 3 = component rate for Nursing. There are 25 PDPM 
Groups A thru Y. 
d.    Character # 4 = component for Non-Therapy Ancillary (NTA). 
There are 6 PDPM Groups A thru F.  
e.    Character # 5 = component for Non-Case Mix (NCM) which do 
not impact the rates selected, but supply information about 
Assessment Level. 
                                                         i.    5-day assessment =  1 
                                                        ii.     IPA  = 0  
   3.    Non-Case-Mix component is fixed rate based on REGION-IND & QRP-
IND [4 options  URBAN, RURAL, URBAN-QRP, & RURAL-QRP 
applied equally to each payment) 
                 
4.    IF SNF-FED-BLEND =1      SET QRP IND TO Y identifies that a 
reduced payment component rate should be selected. 
  
5.    Variable Per Diem adjustment factor applies to PT/OT & NTA 
components only based on the day-in-stay; 
  
6.    Nursing component is adjusted by factor of 1.18 when AIDS Add-On-
Indicator is set to Y ( If input field SNF-PRIN-DIAG-CODE OR [SNF-
OTHER-DIAG-CODE2 thru  
SNF-OTHER-DIAG-CODE25] = 'B20   '. 
 
7. NTA component is adjusted by reassigning a new component rate when 
AIDS Add-On-Indicator is set to Y (( If input field SNF-PRIN-DIAG-
CODE OR [SNF-OTHER-DIAG-CODE2 thru  
SNF-OTHER-DIAG-CODE25] = 'B20   '. 
a.  If reported NTA group is NF, reassigned NTA group is NC 
b.  If reported NTA group is NE, reassigned NTA group is NB 
c.  If reported NTA group is ND, reassigned NTA group is NA 
d.  If reported NTA group is NC, reassigned NTA group is NA 
e.  If reported NTA group is NB, reassigned NTA group is NA 
f.  If reported NTA group is NA, no reassignment is necessary (NA 
represents the highest per diem component rate). 
  
8.       SNF-PDPM-UNITS  & VBP-MULTIPLIER cannot be = zero  
  
9.    SNF-PDPM-PRIOR DAYS > 100 NF processing HALTS & an ERROR 
Code is placed in SNF-RTC  
  
  
On input records with TOB 21x (that is, all provider submitted claims and provider or 
A/B MAC (A) initiated adjustments), Pricer will perform the following calculations in 
numbered order 
for each SNF input character: 
  
.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .   
   
(1)     Capture/select the applicable rate components associated with each HIPPS 
CODE character from rate tables determined by the Region IND, QRP-IND and 
AID Add-On IND (applies to Nursing only). 
  
(2)     Compute the PT-OT-FEE ROUNDED =    HIPPS-PT-RATE-COMP + HIPPS-
OT-RATE-COMP. 
   (3)     Compute the PT-OT-PORTION ROUNDED =   PT-OT-FEE *  PT-OT-UTIL. 
(Utilization Days for PT-OT is determined by summing the PT-OT Variable Per 
Diem factors  
for Total Days (CURRENT-DAYS + PRIOR-DAYS.)). 
  
(4)     Compute the NTA-PORTION ROUNDED =  HIPPS-NTA-RATE-COMP * 
NTA-UTIL.  (Utilization Days for NTA category is determined by summing the 
NTA Variable Per Diem factors  
for Total Days (CURRENT-DAYS + PRIOR-DAYS.). 
  
(5)     Compute NURS-SLP-NCM-PORTION ROUNDED =    (HIPPS-NURSE-
RATE-COMP +    HIPPS-SLP-RATE-COMP +   HIPPS-NCM-RATE-COMP) * 
CURRENT-DAYS (or SNF-PDPM-UNITS).                                                 
  
(6)     Compute TOT-PDPM-CASEMIX-PERDIEM = (PT-OT-PORTION +    NTA-
PORTION +   NURS-SLP-NCM-PORTION).    
ALL 3 PORTIONS ARE ADDED TOGETHER TO GET THE  TOTAL CASE 
MIX PER DIEM. 
  
(7)     Compute LABOR-PORTION ROUNDED =      (TOT-PDPM-CASEMIX-
PERDIEM * PERCENT-2020-LABOR). 
                                                         
(8)     Compute LABOR-ADJUSTED ROUNDED =    (LABOR-PORTION * AREA-
WAGE-INDEX).               
                                                         
(9)     Compute NON-LABOR-PORTION ROUNDED =   (TOT-PDPM-CASEMIX-
PERDIEM * PERCENT-2020-NLABOR) 
                                                         
(10)  Compute TOTAL-LABOR-ADJ-RATE ROUNDED =   (LABOR-ADJUSTED + 
NON-LABOR-PORTION).  
   
(11)  Compute TOTAL-CALC-PAYMENT-RATE ROUNDED = TOTAL-LABOR-
ADJ-RATE.              
                                                          
(12)  Apply the VBP (Value Based Purchasing Factor). 
          Compute SNF-PAYMENT-RATE ROUNDED =  VBP-MULTIPLIER *  TOTAL-
CALC-PAYMENT-RATE.     
                                                               
(13)  Obtain the VBP PAY Difference 
Compute VBP-PAY-DIFF ROUNDED =  SNF-PAYMENT-RATE - TOTAL-CALC-
PAYMENT-RATE. 
 
30.5 - Annual Updates to the SNF Pricer 
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21) 
  Rate and weight information used by the SNF Pricer is updated periodically, usually 
annually.  Updates occur each October, to reflect the fact that SNF PPS rates are effective 
for a Federal fiscal year.  Updates may also occur at other points in the year when 
required by legislation.  The following update items, when changed, are published in the 
Federal Register:" 
 
  The following components of the unadjusted Federal rates for both Rural 
and Urban areas: 
  physical therapy,  
o
  occupational therapy,  
o
  speech-language pathology,  
o
  nursing,  
o
  non-therapy ancillary, and 
o
  non-case-mix. 
o
 
  The case-mix indexes to be used for each case-mix group. 
 
  The factors to be applied in making the area wage adjustment. 
 
  Changes, if any, to the labor and non-labor percentages. 
 
Whenever these update items change, Medicare also publishes a Recurring Update 
Notification to inform providers and A/B MACs (A) about the changes.  These Recurring 
Update Notifications also describe how the changes will be implemented through the 
SNF Pricer. 
 
40 - Special Inpatient Billing Instructions 
(Rev. 1733; Issued: 05-08-09; Effective Date:  10-01-06; Implementation Date:  04-
27-09) 
The SNFs bill upon the following: 
  Discharge; 
  Benefit exhaustion; (Note: Submit both full and partial benefits exhaust claims 
monthly) 
  A decrease in level of care to less than skilled care; or  
  Monthly (and if necessary, monthly thereafter). 
Each bill must include all diagnoses applicable to the admission.  However, SNFs do not 
include charges that were billed on an earlier bill.  The from date must be the day after 
the through date on the prior bill. 
 
40.1 - Submit Bills in Sequence 
(Rev. 1, 10-01-03) 
SNF-517.13, A3-3603.2 
  The SNFs must submit bills in sequence for each beneficiary they service.  The A/B 
MAC (A) will return to the SNF a continuing stay bill if the prior bill has not been 
processed.  When the A/B MAC (A) receives an out-of-sequence claim for a continuous 
stay, it will search its history for the prior adjudicated claim.  If the prior bill has not been 
finalized, the A/B MAC (A) will return to the provider (RTP), the incoming bill, request 
that the prior bill be submitted first, and the returned bill only be submitted after the SNF 
receives notice of adjudication of the prior bill.  A typical error message follows: 
 
Bills for a continuous stay or admission must be submitted in the same 
sequence in which services are furnished.  If the provider has not already 
done so, please submit the prior bill.  Then, resubmit this bill after you 
receive the remittance advice for the prior bill. 
 
If the prior bill was submitted, the SNF will hold the returned bill until it receives a 
remittance advice for the prior bill. 
 
40.2 - Reprocessing Inpatient Bills in Sequence 
(Rev. 2245, Issued: 06-16-11, Effective: 08-01-11, Implementation: 08-01-11) 
 
When a beneficiary experiences multiple admissions (to the same or different facilities) 
during a benefit period, claims are processed by CWF in the same order that they are 
received, regardless of the dates on which expenses were incurred.  This first-in-first-out 
method of processing requests for payment facilitates prompt handling of claims. 
 
If a SNF, any beneficiary, or secondary insurer have increased liability as a result of 
CWFs first-in/first-out (FI/FO) processing, the SNF must notify the A/B MAC (A) to 
arrange reprocessing of all affected claims.  This approach is not applicable if the liability 
stays the same, e.g., if the coinsurance or deductible amounts are applied on the second 
stay instead of the first, but there is no issue with regard to the effective date of 
supplementary coverage or if the beneficiary is responsible for payment of the first claim 
instead of the second. 
 
The A/B MAC (A) will verify and cancel any bills posted out-of-sequence and request 
that any other A/B MAC (A) involved also cancel any affected bills.  The A/B MAC (A) 
will reprocess all bills in the benefit period in the sequence of the beneficiarys stays to 
properly allocate days where payment is made in full by Medicare and to identify those 
days where the beneficiary is required to pay coinsurance. 
 
40.3 - Determining Part A Admission Date, Discharge Date, and 
Utilization Days 
(Rev. 1, 10-01-03) 
SNF-515.4, SNF-515.4 
 
40.3.1 - Date of Admission 
(Rev. 229, Issued 07-20-04 Effective/Implementation 08-19-04) 
  The beneficiary, entitled to Part A benefits, becomes a SNF resident for Part A PPS 
billing purposes when admitted to a Medicare certified SNF or DPU.  This could be a 
first time admission or a readmission following events described in 40.3.2.  Services on 
and after this day are included in the PPS rate and cannot be billed by other providers and 
suppliers unless excluded as described in this chapter. 
 
40.3.2 - Patient Readmitted Within 30 Days After Discharge 
(Rev. 10569, Issued: 01-14-21, Effective: 04-01-21, Implementation: 04-05-21)  
 
A patient is deemed not to have been discharged if the time between SNF discharge and 
readmission to the same or another SNF is within 30 days. (See the Medicare Benefit 
Policy Manual, Chapter 8, Coverage of Extended Care Services (SNF) Under Hospital 
Insurance, 20.2.) However, if more than 30 days elapse after the patients discharge 
from a participating SNF or after his/her transfer to a nonparticipating part of the 
institution, the patient must again meet the 3-day hospital stay requirement to become 
eligible for SNF benefits. When a discharge bill has been sent and the patient is 
readmitted to the SNF within 30 days, the SNF must submit another bill, which shows the 
current admission date and the following additional data.  The SNF must complete 
condition code 57 on the claim to indicate the patient previously received Medicare 
covered SNF care within 30 days of the current SNF admission.  The SNF must 
complete occurrence span code 70 to indicate the qualifying stay dates for a hospital 
stay of at least 3 days which qualifies the patient for payment of the SNF level of care 
services billed on the claim. If a discharge bill has not been sent at the time of 
readmission, the SNF must submit an interim bill with occurrence code 74 to show the 
from/through dates of the leave of absence (the period the patient was not in the facility) 
and the number of noncovered days. For claims that contain both covered days and 
noncovered days, and those noncovered days are the responsibility of the beneficiary 
(e.g., days submitted for noncovered level of care), the provider should append span code 
76 to indicate the days the beneficiary is liable. 
 
40.3.3 - Same Day Transfer 
(Rev. 4001, Issued: 03-16-18, Effective: 06-19-18, Implementation: 06-19-18) 
 
The day of admission counts as a utilization day, except in the situation where the patient 
was admitted with the expectation that he remain overnight but was transferred to another 
participating provider before the following midnight.  In this instance, the first provider 
completes the bill as follows: 
 
  Indicate 0 in Covered Days; 
 
  Insert condition code 40 to indicate the patient was transferred from one 
participating provider to another before the midnight immediately following the 
admission to the first provider; and, 
    Admission date, statement from and through dates are the same. 
 
No payment is made to the originating participating provider.  Instead, the participating 
provider to which the patient was transferred counts the admission day as a utilization 
day that includes the day of admission and may bill the HIPPS default code. 
 
If a patient is transferred from a Medicare participating facility to a nonparticipating 
facility the day of admission counts as a utilization day and the Medicare-participating 
facility may bill the HIPPS default code. 
 
These general rules apply to transfers between SNFs and between a hospital and an SNF. 
However, under these same circumstances, if the two providers represent an institution 
composed of a participating hospital and a distinct part participating SNF, the first 
provider cannot bill for accommodations, but may bill for ancillary charges. 
 
40.3.4 - Situations that Require a Discharge or Leave of Absence 
(Rev. 4001, Issued: 03-16-18, Effective: 06-19-18, Implementation: 06-19-18) 
 
Medicare systems are set up so that the SNF need not submit a discharge bill when the 
situation is that the beneficiary (who leaves the SNF and then returns before the 
following midnight) receives outpatient services from a Medicare participating hospital, 
CAH, or other appropriate provider during his/her absence.  Edits allow hospitals and 
CAHs to bill for these services for a beneficiary in a Part A PPS stay.  Receipt of 
outpatient services from another provider does not normally result in a SNF discharge. 
 
Two situations force a discharge from a SNF:  1) the beneficiarys admission as an 
inpatient to a Medicare participating hospital or CAH, or 2) the beneficiarys transfer to 
another SNF for inpatient services.  A beneficiary cannot be an inpatient in more than one 
facility at a time.  Consequently, the SNF must submit a discharge bill if either of these 
events occur. 
 
If the patient is readmitted to the SNF, the SNF should submit a new bill (TOB 211 or 
212) with a new admission date.  See 40.3.2, Patient Readmitted Within 30 days After 
Discharge, for further instructions. 
 
Bills for excluded services (identified in 20 of this chapter) rendered by participating 
hospitals, CAHs, or other appropriate providers may be paid to the rendering provider in 
addition to the Part A PPS payment made to the SNF.  Other outpatient services furnished 
to a resident in a Part A PPS stay by another provider/supplier must be billed by the SNF.   Home health or outpatient services provided during a leave of absence do not affect the 
leave and no discharge bill is required. 
 
Home health services are not payable unless the patient is confined to his home, and 
under Medicare regulations, a SNF cannot qualify as a home.  Where the beneficiary 
receives services from a home health agency, the home health agency is responsible for 
billing. 
 
If the beneficiary is formally discharged or otherwise departs for reasons other than 
described above but then, is readmitted or returns before the following midnight, he is not 
considered discharged.  The SNF is responsible for billing for services during the period 
of absence, unless such services are otherwise excluded from Part A PPS payment or are 
excluded from Medicare coverage (see 10.1). 
 
NOTE:  This instruction only applies to Medicare fee-for-service beneficiaries in a 
participating SNF. 
 
40.3.5 - Determine Utilization on Day of Discharge, Death, or Day 
Beginning a Leave of Absence 
(Rev. 4001, Issued: 03-16-18, Effective: 06-19-18, Implementation: 06-19-18) 
SNF-517.6.B, A3-3103.4  
 
Generally, the day of discharge, death, or a day on which a patient begins a leave of 
absence, is not counted as a utilization day. (See the Medicare Benefit Policy Manual, 
Chapter 3, Duration of Covered Inpatient Services.) This is true even where one of 
these events occurs on a patients first day of entitlement or the first day of a providers 
participation in the Medicare program. In addition, a benefit period may begin with a stay 
in a hospital or SNF, on that day.  
 
The exception to the general rule of not charging a utilization day for the day of 
discharge, death, or day beginning a leave of absence is where the patient is admitted 
with the expectation that he will remain overnight but is discharged, dies, or is transferred 
to another, nonparticipating provider (or to a nonparticipating portion of the same 
provider) before the following midnight. In these instances, such a day counts as a 
utilization day. This exception includes the situation where the beneficiary was admitted 
(with the expectation that he would remain overnight) on either the first day of his 
entitlement or the providers first day of participation, and on the same day he was 
discharged, died, or transferred to a nonparticipating provider.  
 
Payment is not made under PPS unless a covered day can be billed. Also, for a 
noncovered day such as the day of discharge (for which no payment is possible under 
PPS), separate billing is not allowed for ancillary services. Ancillary charges for such 
days have already been included in the PPS rates for those days that can be billed. This is 
because, in accordance with the longstanding instructions in Pub. 15-1, Provider  Reimbursement Manual, Part I, chapter 22, section 2205.1, ancillary charges for services 
furnished on the day of (but before the actual moment of) discharge are included on the 
SNFs cost report and reflected in final cost settlement (see also 40.6.3). Accordingly, 
such charges have been built into the PPS base. As a result, even though the day of 
discharge itself is not a Medicare-covered day for the SNF, the PPS per diem for all of 
the covered days leading up to the day of discharge is somewhat higher than it otherwise 
would have been, reflecting the historical cost of these day-of-discharge services.  
 
When a patient is discharged on the first day of a providers participation or the first day 
of the patients entitlement, complete the bill as follows:  
 
 Admission date is the actual date of admission;  
 
 From date of service is the date the patient became entitled or date the SNF began 
participation; and  
 
 The number of noncovered days = 1.  
 
40.3.5.1 - Day of Discharge or Death Is the Day Following the Close of 
the Accounting Year 
(Rev. 1, 10-01-03) 
SNF-517.2 
 
Where the day of discharge or death is the day following the close of the cost reporting 
period, the ancillary charges for services rendered on that day must be included in the bill 
submitted for services in the prior accounting year, which includes the covered days for 
the billing period in that year.  In such cases, Statement Covers Period, should show the 
date of discharge or death as the through date.  The Patient Status should reflect the 
date of discharge or death, as appropriate.  The SNF uses the same billing method when 
developing accrued non-Medicare charges.  For cost settlement purposes, ancillary 
charges incurred in the new fiscal year, but billed under the prior fiscal year, are 
considered charges for the prior fiscal year. 
 
40.3.5.2 - Leave of Absence 
(Rev. 4001, Issued: 03-16-18, Effective: 06-19-18, Implementation: 06-19-18) 
 
A leave of absence for the purposes of this instruction is a situation where the patient is 
absent, but not discharged, for reasons other than admission to a hospital, other SNF, or 
nonparticipating portion of the same institution. If the absence exceeds 30 consecutive 
days, the 3-day prior stay and 30-day transfer requirements, as appropriate, must again be 
met to establish re-entitlement to SNF benefits.  
 
Leave of absence (LOA) days are shown on the bill with revenue code 018X and LOA 
days as units. However, charges for LOA days are shown as zero on the bill, and the SNF 
cannot bill the beneficiary for them except as specified in Chapter 1 of this manual at 
30.1.1.1. Occurrence span code 74 is used to report the LOA from and through dates.  Providers should review the RAI manual to clarify situations where an LOA is not 
appropriate, for example observation stays in a hospital lasting greater than 24 hours. 
 
40.4 - Accommodation Charges Incurred in Different Accounting Years 
(Rev. 1, 10-01-03) 
SNF-517.1 
 
The SNF must not put accommodation charges incurred in different accounting years on 
the same bill.  (See 40.3.5.1 when billing for ancillary charges for services furnished on 
the day of discharge or death when it is also the day after the end of the accounting year.)  
At the end of the accounting year, the SNF must submit a bill that contains the charges 
for all services furnished to the patient since the last bill and through the end of that year.  
The SNF shows services furnished in the following accounting year on a separate bill. 
 
 
40.5 - Billing Procedures for Periodic Interim Payment (PIP) Method of 
Payment 
(Rev. 3220, Issued: 03-16-15, Effective: ICD-10: Upon Implementation of ICD-10, 
ASC-X12: 01-01-12, Implementation: 10-01-14, ICD-10: Upon Implementation of 
ICD-10 ASC X12: 09-16-14) 
 
The SNFs using the PIP method of payment follow the regular billing instructions in 
Medicare Claim Processing Manual, Chapter 25. 
 
See the Medicare Claims Processing Manual, Chapter 1, General Billing Requirements, 
80.4, for requirements SNFs must meet and A/B MACs (A) must monitor to continue 
PIP reimbursement.  Refer to the Medicare Claims Processing Manual, Chapter 25 for 
further information about completing the claim. 
 
40.6 - Total and Noncovered Charges 
(Rev. 10569, Issued: 01-14-21, Effective: 04-01-21, Implementation: 04-05-21) 
 
ASC X12 837 Institutional Claim See the related implementation guide on the official 
Washington Publishing Company website. Form CMS -1450 For each cost center for 
which a separate charge is billed (type of accommodation or ancillary), a revenue code is 
assigned and is entered on the claim with the related charges. On Form CMS-1450 the 
appropriate numeric revenue code is entered in FL 42 to explain each charge in FL 47. 
Additionally, there is no fixed Total line in the charge area. Instead, revenue code 
0001 is always entered last in FL 42. Thus, the adjacent charge entry, in FL 47, is the 
sum of charges billed. This is also the same line on which noncovered charges, if any, in 
FL 48, are summed. The total charge for all services, covered and noncovered, will 
generally be shown. See 40.6.1 below, for certain exceptions. In the noncovered 
charges column (FL48) enter the amount of any noncovered charge except where:  The 
A/B MAC (A) has notified the SNF that payment can be made under the limitation of 
liability provisions; and  A payer primary to Medicare is involved. (See the Medicare 
Secondary Payer [MSP] Manual, Chapter 3, MSP Provider Billing Requirements, and  Chapter 4, Contractor Prepayment Processing Requirements.) Where a bill is submitted 
for a period including both covered and noncovered days (e.g., days submitted for 
noncovered level of care), the SNF must list the charges for noncovered days under 
noncovered charges. Refer to the Medicare Claims Processing Manual, Chapter 25 for 
further information about completing the claim. For claims that contain both covered 
days and noncovered days, and those noncovered days are the responsibility of the 
beneficiary (e.g., days submitted for noncovered level of care), the provider should 
append span code 76 to indicate the days the beneficiary is liable. 
 
40.6.1 - Services in Excess of Covered Services 
(Rev. 3220, Issued: 03-16-15, Effective: ICD-10: Upon Implementation of ICD-10, 
ASC-X12: 01-01-12, Implementation: 10-01-14, ICD-10: Upon Implementation of 
ICD-10 ASC X12: 09-16-14) 
 
Where items and services are furnished which are more expensive or in excess of the 
services covered by the program, the SNF will make the following entries in the Total 
Charges and Noncovered fields on the bill: 
 
  If the patient did not request such excess or more expensive services, the patient 
may not be charged for them, and only the services covered by the program are 
shown in total charges.  No entry is made in noncovered charges in this situation.  
(However, where all patients are routinely billed for such excess or more 
expensive items, total charges may reflect the excess items or services as 
discussed in total and noncovered charges, above.); 
 
  If the patient did request such excess or more expensive services, the SNF may 
charge the patient for them.  In this case, the SNF show the line item total charge 
(any customary charges covered by the program plus the excess charges).  The 
excess charges that will be billed to the patient are shown in noncovered charges. 
 
  In the same situation as above, except that the SNF will not bill the patient for the 
excess services.  Instead the SNF will show only the customary charges for 
covered services in total charges and make no entry in noncovered charges. 
 
40.6.2 - Showing Discounted Charges 
(Rev. 1, 10-01-03) 
SNF-517.11 
 
The SNFs do not show credit or minus entries on the bill.  Where the SNF gives a 
discount to some patients, they show charges in one of two ways: 
 
1. SNFs show the charges as the full, undiscounted charge if full undiscounted charge 
data is accumulated for all patients for the purposes of the final cost report; or 
 
2. They show the discounted charges as the only charges, if the SNF, for the purposes 
of the final cost report, accumulates charges for all patients at the discounted rate. 
  40.6.3 - Reporting Accommodations on the Claim  
(Rev. 3220, Issued: 03-16-15, Effective: ICD-10: Upon Implementation of ICD-10, 
ASC-X12: 01-01-12, Implementation: 10-01-14, ICD-10: Upon Implementation of 
ICD-10 ASC X12: 09-16-14) 
 
See the Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services, for an 
explanation of the rules when other than semi-private accommodations are furnished that 
apply to SNFs as well as hospitals.  The type of accommodation furnished at the time of 
the SNF census-taking hour determines the applicable revenue code.  Where a patient is 
admitted with the expectation that he will remain overnight, but on the same day is 
discharged, dies, or is transferred prior to the census, the revenue code is determined by 
the type of accommodation furnished at the time of the patients discharge, death, or 
transfer. 
 
Payment is based on the PPS rate, not on accommodation levels.  See 40.6.1 where the 
patient requests more expensive accommodations or patient convenience items. 
 
The determination of charges does not affect the determination of inpatient utilization 
days or when a patient may be considered an inpatient for Medicare purposes as outlined 
in the Medicare Benefit Policy Manual, Chapter 8, Coverage of Extended Care (SNF) 
Services Under Hospital Insurance, 50 and 60.2.  Refer to the Medicare Claims 
Processing Manual, Chapter 25 for further information about billing. 
 
SNFs show total charges for accommodation for the entire billing period and charges for 
any noncovered days in noncovered charges.) 
 
The accommodation days do not include the day of death or discharge, even where the 
discharge was late.  However, where the SNF customarily makes an extra charge for a 
late discharge, they include this amount in total charges with the appropriate 
accommodation revenue code.  The day of discharge is not included in Covered Days 
even though an extra charge is included.  Where the late discharge was for the patients 
convenience and not for any medical necessity, SNFs enter the charge for late discharge 
as a noncovered charge.  Where the late discharge is for a medical reason, the charge is 
covered.  (See the Medicare Benefit Policy Manual, Chapter 8, Coverage of Extended 
Care (SNF) Services Under Hospital Insurance, 60.3.) 
 
The charges for accommodations reflect only the total charges for general routine 
services as defined in 2202.6 and 2203.1 of the Medicare Provider Reimbursement 
Manual.  All charges, which are charged to every patient for every patient day, are 
included in the routine accommodation charge. 
 
SNFs bill ancillary charges for day of discharge, death or the day on which a leave of 
absence begins, under the proper revenue code. 
 
Where the patient is discharged on his first day of entitlement or the first day of the SNF 
participation in the Medicare program, they submit a bill with no accommodation charge, 
but with ancillary charges.   
Where some of the days cannot be paid under Part A because benefits were exhausted 
before discharge, death, or the day on which a leave of absence began, SNFs show the 
charges for days after benefits where exhausted under noncovered charges, and enter the 
appropriate occurrence code, e.g., A3, and the date benefits are exhausted.  See the 
Medicare Claims Processing Manual, Chapter 7, SNF Part B Billing, 10, for billing 
under Part B in such circumstances. 
 
40.6.4 - Bills with Covered and Noncovered Days 
(Rev. 3220, Issued: 03-16-15, Effective: ICD-10: Upon Implementation of ICD-10, 
ASC-X12: 01-01-12, Implementation: 10-01-14, ICD-10: Upon Implementation of 
ICD-10 ASC X12: 09-16-14) 
 
Any combination of covered and noncovered days may be billed on the same bill.  It is 
important to record a day or charge as covered or noncovered because of the following: 
 
  Beneficiary utilization is recorded based upon days during which the patient 
received hospital or SNF accommodations, including days paid by Medicare and 
days for which the provider was held liable for reasons other than medical 
necessity or custodial care. 
 
  The provider may claim credit on its cost report only for covered 
accommodations, days and charges for which actual payment is made.  Provider 
liable days and charges are not included on the cost report.  Data from the bill 
payment process are used in preparing the cost report. 
 
SNFs show noncovered charges for denied or noncovered days, which will not be paid.  
The SNF submits the bill with occurrence span code 76 and completes the from/through 
dates to report periods where the beneficiary is liable.  Occurrence span code 77 is used 
to report periods of noncovered care where the SNF is liable.  If applicable, the FISS 
system will automatically assign occurrence code A3 indicating the last date for which 
benefits are available or the date benefits were exhausted. 
 
The A/B MAC (A) will use Occurrence Span Code 79 (a payer only code sent to CWF) 
to report periods of noncovered care due to lack of medical necessity or custodial care for 
which the provider is held liable.  Periods of beneficiary liability and provider liability 
may be reported on one bill.  Report all noncovered days. 
 
See Chapter 25, Completing and Processing the CMS-1450 Data Set, for a complete 
description of billing data elements.  See the Medicare Claims Processing Manual, 
Chapter 30, Limitation on Liability, for determining SNF liability. 
 
The provider is always liable unless the appropriate notice is issued.  If the SNF issues 
the appropriate notice, and the beneficiary agrees to make payment either personally or 
through a private insurer, the days will not be charged towards the 100-day benefit 
period.  Notice requirements for periods of noncoverage are found in Chapter 30, 70. 
  40.6.5 - Notification of Limitation on Liability Decision 
(Rev. 133, 04-02-04) 
SNF-517.8 
 
Detailed instructions and application of limitation on liability is found in The Medicare 
Claims Processing Manual, Chapter 30, Limitation on Liability.  The limitation on 
liability decision is made by the A/B MAC (A) when the medical evidence and admission 
notice, or the bill is submitted.  When coverage is denied, notification will be by 
telephone, if possible, so written notice can be provided to the patient immediately.  
When it is determined during the course of a beneficiarys stay in an SNF that the care is 
not covered but both the beneficiary and the SNF are entitled to limitation on liability, the 
Medicare program may make payment for the noncovered services for a grace period of 
one day (24 hours) after the date of notice to the SNF or to the beneficiary, whichever is 
earlier.  If it is determined that more time is required in order to arrange post-discharge 
care, up to 1 additional grace period day may be paid for. 
 
Limitation of liability may apply to Part A and Part B services furnished by the provider. 
 
40.7 - Ending a Benefit Period 
(Rev. 930, Issued: 04-28-06, Effective: 10-01-06, Implementation: 10-02-06) 
 
A benefit period ends 60 days after the beneficiary has ceased to be an inpatient of a 
hospital and has not received inpatient skilled care in a SNF during the same 60-day 
period. 
 
When the SNF resident's health has improved to the point where he or she no longer 
needs or receives the level of skilled care required for Part A coverage, the SNF must bill 
one of the two following scenarios: 
 
1.  For the resident that leaves the Medicare-certified SNF or DPU: 
 
a.  Submit a final discharge bill, and  
 
b.  Any services rendered after the discharge and billed by the SNF should be 
submitted on a 23x. 
 
2.  For the resident that remains in the Medicare-certified SNF or DPU after the 
skilled level of care has ended: 
 
a.  Submit the last skilled care claim with an occurrence code 22 to indicate 
the date active care ended. i.e., date covered SNF level of care ended, and patient status 
code 30 to indicate the patient is still a resident in the Medicare-certified SNF or DPU; 
 
b.  Any Part B covered services rendered and billed by the SNF after the 
skilled care ended should be submitted on a 22x; and 
 
c.  All therapies must be billed by the SNF on the 22x.   
For additional instructions on ending a benefit period go to the Medicare General 
Information, Eligibility, and Entitlement Manual, Chapter 3, 10.4.2. 
 
40.8 - Billing in Benefits Exhaust and No-Payment Situations 
(Rev. 4491, Issued: 01-09- 20, Effective: 04-01-20, Implementation: 04-06-20) 
 
An SNF is required to submit a bill for a beneficiary that has started a spell of illness 
under the SNF Part A benefit for every month of the related stay even though no benefits 
may be payable.  CMS maintains a record of all inpatient services for each beneficiary, 
whether covered or not.  The related information is used for national healthcare planning 
and also enables CMS to keep track of the beneficiarys benefit period.  These bills have 
been required in two situations:  1) when the beneficiary has exhausted his/her 100 
covered days under the Medicare SNF benefit (referred to below as benefits exhaust bills) 
and 2) when the beneficiary no longer needs a Medicare covered level of care (referred to 
below as no-payment bills). 
 
For benefits exhaust bills, an SNF must submit monthly a benefits exhaust bill for those 
patients that continue to receive skilled care and also when there is a change in the level 
of care regardless of whether the benefits exhaust bill will be paid by Medicaid, a 
supplemental insure, or private payer.  There are two types of benefits exhaust claims:  1) 
Full benefits exhaust claims: no benefit days remain in the beneficiarys applicable 
benefit period for the submitted statement covers from/through date of the claim and 2) 
Partial benefits exhaust claims: only one or some benefit days, in the beneficiarys 
applicable benefit period, remain for the submitted statement covers from/through date of 
the claim.  Monthly claim submission of both types of benefits exhaust bills are required 
in order to extend the beneficiarys applicable benefit period posted in the Common 
Working File (CWF).  Furthermore, when a change in level of care occurs after 
exhaustion of a beneficiarys covered days of care, the provider must submit the benefits 
exhaust bill in the next billing cycle indicating that active care has ended for the 
beneficiary.  
 
NOTE:  Part B 22x bill types must be submitted after the benefits exhaust claim has been 
submitted and processed. 
 
In addition, SNF providers must submit no-payment bills for beneficiaries that have 
previously received Medicare-covered skilled care and subsequently dropped to a non-
covered level of care but continue to reside in a Medicare-certified area of the 
facility.  Consolidated Billing (CB) legislation indicates that physical therapy, 
occupational therapy, and speech language pathology services furnished to SNF residents 
are always subject to SNF CB.  This applies even when a resident receives the therapy 
during a non-covered stay in which the beneficiary who is not eligible for Part A 
extended care benefit still resides in an institution (or part thereof) that is Medicare-
certified as a SNF.  SNF CB edits require the SNF to bill for these services on a 22x 
(inpatient part B) bill type.  NOTE: Unlike with benefits exhaust claims, Part B 22x bill 
types may be submitted prior to the submission of bill type 210 no payment claims.  
  If a facility has a separate, distinct non-skilled area or wing then beneficiaries may be 
discharged to this area using the appropriate patient discharge status code and no- 
payment bills would not be required.  In addition, SNF CB legislation for therapy 
services would not apply for these beneficiaries. 
 
No-payment bills are not required for non-skilled beneficiary admissions.  As indicated 
above, they are only required for beneficiaries that have previously received covered care 
and subsequently dropped to non-covered care and continue to reside in the certified area 
of the facility.  
 
NOTE:  Providers may bill benefits exhaust and no payment claims using the default 
HIPPS code AAA00 prior to October 1, 2019 and ZZZZZ October 1, 2019 and after, in 
addition to an appropriate room & board revenue code only.  No further ancillary services 
need be billed on these claims. 
 
SNF providers and A/B MACs (A) shall follow the billing guidance provided below for 
the proper billing of benefits exhaust bills and no-payment bills. 
 
1)  SNF providers shall submit benefits exhaust claims for those beneficiaries that 
continue to receive skilled services as follows: 
 
a)   Full or partial benefits exhaust claim. (Submitted monthly) 
 
i)  Bill Type = Use appropriate covered bill type (i.e., 211, 212, 213 or 214 for 
SNF and 181, 182, 183 or 184 for Swing Bed (SB).  NOTE:  Bill types 210 or 
180 should not be used for benefits exhaust claims submission). 
 
ii)  Occurrence Span Code 70 with the qualifying hospital stay dates. 
 
iii) Covered Days and Charges = Submit all covered days and charges as if 
beneficiary had days available. 
 
iv) Value Code 09 (First year coinsurance amount) 1.00 (If applicable, the FISS 
will assign the correct coinsurance amount based off the CWF response). 
 
v)  Patient Status Code = Use appropriate code. 
 
b)   Benefits exhaust claim with a drop in level of care within the month; Patient 
remains in the Medicare-certified area of the facility after the drop in level of 
care. 
 
i)  Bill Type = Use appropriate bill type (i.e., 212 or 213 for SNF and 182 or 183 
for SB.  NOTE:  Bill types 210 or 180 should not be used for benefits exhaust 
claims submission). 
 
ii)  Occurrence Span Code 70 with the qualifying hospital stay dates.   
iii) Occurrence Code 22 (date active care ended, i.e., date covered SNF level of 
care ended) = include the date active care ended; this should match the 
statement covers through date on the claim. 
 
iv) Covered Days and Charges = Submit all covered days and charges as if the 
beneficiary had days available up until the date active care ended. 
 
v)  Value Code 09 (First year coinsurance amount) 1.00 (If applicable, the FISS 
will assign the correct coinsurance amount based off the CWF response). 
 
vi) Patient Status Code = 30 (still patient). 
 
c)   Benefits exhaust claim with a patient discharge. 
 
i)  Bill Type = 211 or 214 for SNF and 181 or 184 for SB (NOTE: Bill types 210 
or 180 should not be used for benefits exhaust claims submission). 
 
ii)  Covered Days and Charges = Submit all covered days and charges as if 
beneficiary had days available up until the date active care ended. 
 
iii) Value Code 09 (First year coinsurance amount) 1.00 (If applicable, the FISS 
will assign the correct coinsurance amount based off the CWF response). 
 
iv) Patient Status Code = Use appropriate code other than patient status code 30 
(still patient). 
 
NOTE:  Billing all covered days and charges allow the Common Working File (CWF) to 
assign the correct benefits exhaust denial to the claim and appropriately post the claim to 
the patients benefit period.  Benefits exhaust bills must be submitted monthly. 
 
2)  SNF providers shall submit no-payment claims for beneficiaries that previously 
dropped to non-skilled care and continue to reside in the Medicare-certified area of 
the facility using the following options.  
 
a)   Patient previously dropped to non-skilled care.  Provider needs Medicare 
denial notice for other insurers. 
 
i)  Bill Type = 210 (SNF no-payment bill type) or 180 (SB no-payment bill type) 
 
ii)  Statement Covers From and Through Dates = days provider is billing, which 
may be submitted as frequently as monthly, in order to receive a denial for 
other insurer purposes.  No-payment billing shall start the day following the 
date active care ended. 
  iii) Days and Charges = Non-covered days and charges beginning with the day 
after active care ended. 
 
iv) Condition Code 21 (billing for denial). 
 
v)  Patient Status Code = Use appropriate code. 
 
b)   Patient previously dropped to non-skilled care.  In these cases, the provider 
must only submit the final discharge bill that may span multiple months but 
must be as often as necessary to meet timely filing guidelines. 
 
i)  Bill Type = 210 (SNF no-payment bill type) or 180 (SB no-payment bill type) 
 
ii)  Statement Covers From and Through Dates = days billed by the provider, 
which may span multiple months, in order to show final discharge of the 
patient.  No-payment billing shall start the day following the date active care 
ended. 
 
iii) Days and Charges = Non-covered days and charges beginning with the day 
after active care ended. 
 
iv) Condition Code 21 (billing for denial). 
 
v)  Patient Status Code = Use appropriate code other than patient status code 30 
(still patient). 
 
NOTE: No pay bills may span both provider and Medicare fiscal year end dates. 
 
Refer to Chapter 25 for further information about billing.  
  40.8.1  SNF Spell of Illness Quick Reference Chart 
(Rev.4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19) 
 
 
Patient Is 
If in non-
Patient's  In  Is the 
Medicare 
Medicare  Medicare  Inpatient 
Level of  Area, the 
SNF Part A  Certified  Spell of                                Billing Action 
Care   Facility Meets 
Benefits Are  Area of  Illness 
the Definition 
Exhausted  the  Continued?  
of a SNF ** 
Facility * 
YES  YES  N/A   YES  Submit Monthly Covered Claim. 
NO  YES  N/A   YES  Submit Monthly Covered Claim. 
Medicare  YES  NO  YES  YES  Submit Monthly Covered Claim. 
Skilled  
Patient should be returned to certified area for Medicare to be  
NO  NO  YES  YES  billed. Submit Monthly Covered Claim. 
Facility should determine whether it would be  
appropriate to send patient back to a certified area for  
NO  NO  NO  NO  Medicare coverage. 
Not 
Do not submit claim if pt came in non-skilled.  Otherwise,  
Medicare 
submit no-pay claim w/ discharge status code when patient  
Skilled 
YES  NO  NO  NO  leaves the certified area.  Do not submit claim if pt came in non-skilled.  Otherwise,  
submit no-pay claim w/ discharge status code when patient  
YES  YES  N/A   NO  leaves the certified area. 
Do not submit claim if pt came in non-skilled.  Otherwise,  
submit no-pay claim w/ discharge status code when patient leaves the 
NO  YES  N/A   NO  certified area. 
Do not submit claim if pt came in non-skilled.  Otherwise, 
 submit no-pay claim w/ discharge status code when patient  
NO  NO  YES  NO  leaves the certified area. 
Do not submit claim if pt came in non-skilled.  Otherwise, 
 submit no-pay claim w/ discharge status code when patient  
YES  NO  YES  NO  leaves the certified area. 
* Whether the facility considers a patient's bed in the certified area to be a Medicare bed or not has no effect on whether the spell of 
illness is continued and has no effect on the SNF's action. 
** In some states, licensing laws for all nursing homes have incorporated requirements of the basic SNF definition (Social Security 
Act 1819(a)(1)). When this is the case, any nursing home in such a state would be considered to meet this definition (see CMS 
Internet-Only Manual, Pub. 100-7, Chapter 2, 2164 at www.cms.hhs.gov/manuals/ on the CMS website). 
  40.8.2 - Billing When Qualifying Stay or Transfer Criteria are Not Met 
(Rev. 1618, Issued: 10-24-08, Effective: 04-01-09; Implementation: 04-06-09) 
SNF providers are required to submit claims to Medicare for beneficiaries that receive a 
skilled level of care.  This includes beneficiaries that do not meet the qualifying stay or 
transfer criteria.  Although these claims will not be paid by Medicare, providers must 
submit these claims as covered in order to extend existing beneficiary spells of illness in 
CWF.  A prior qualifying hospital stay (occurrence span code 70) would not be 
applicable and shall not be included with these claims.  This will allow Medicare systems 
to deny the claim for the appropriate reason.  
Note:  This instruction includes beneficiaries that were previously admitted for skilled 
care then subsequently drop to non-skilled for greater than 30 days and then require 
skilled care again but do not have a new qualifying hospital stay. 
 
40.9 - Other Billing Situations 
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21) 
 
A. Demand Bills 
 
Where the SNF believes that a covered level of care has ended but the beneficiary 
disagrees, they report occurrence code 21 (UR notice received) or 22 (date active care 
ended) as applicable and condition code 20 indicating the beneficiary believes the 
services are covered beyond the occurrence date. 
 
See the Medicare Claims Processing Manual, Chapter 1, General Billing Requirements, 
60.3, for instructions on advance beneficiary notices and demand bills. 
 
Refer to the Medicare Claims Processing Manual, Chapter 25 for further information 
about billing. 
 
B. Request for Denial Notice for Other Insurer 
 
The SNFs complete a noncovered bill and enter condition code 21 to indicate a request 
for a Medicare denial notice.  Refer to Chapter 25 further information about billing. 
 
C. Another Insurer is Primary to Medicare 
 
See the Medicare Secondary Payer (MSP) Manual, Chapter 3, MSP Provider Billing 
Requirements and Chapter 5, Contractor Prepayment Processing Requirements, for 
submitting claims for secondary benefits to Medicare.  Refer to the Medicare Claims 
Processing Manual, Chapter 25 for further information about billing. 
 
D. Special MSN Messages 
 
The Medicare Prescription Drug Improvement and Modernization Act of 2003 requires 
that Medicare Summary Notices (including SNF claims for post-hospital extended care  services provided under Part A) report the number of covered days remaining in the given 
spell of illness.  This requirement became effective July 6, 2004. 
 
E. Interrupted Stay 
 
Refer to the Medicare Claims Processing Manual, Chapter 6, Interrupted Stay Policy, 
120.2, for information about billing when a patient returns to a covered level of care 
after an interrupted stay. 
 
 
50 - SNF Payment Bans, or Denial of Payment for New Admissions 
(DPNA) 
(Rev. 1555; Issued:  07-18-08; Effective Date:  01-01-09; Implementation Date: 01-
05-09) 
 
Under the Act at 1819(h) and 1919(h) and CMS regulations at 42 CFR 488.417, CMS 
may impose a denial of payment for new admissions (DPNA) against a SNF when a 
facility is not in substantial compliance with requirements of participation. To understand 
the effect on coverage of SNF services, see the Medicare Benefit Policy Manual, Chapter 
8, Coverage of Extended Care (SNF) Services Under Hospital Insurance, 20.3 - 
20.3.1.6. 
 
50.1 - Effect on Utilization Days and Benefit Period 
(Rev. 1555; Issued:  07-18-08; Effective Date:  01-01-09; Implementation Date: 01-
05-09) 
 
Payment sanctions are applied to days that would otherwise be Part A-payable; i.e., the 
care is covered but no payment will be made to the provider. Therefore, if the Medicare 
participating SNF assumes responsibility for the beneficiarys costs during the sanction 
period, it will be considered the same as a program payment, and the days will count 
towards the 100-day benefit period. 
 
In situations where the beneficiary is subject to the payment ban, but the provider fails to 
issue the proper beneficiary liability notice, the provider is liable for all services normally 
covered under the Medicare Part A benefit.  Since the beneficiary is receiving benefits, 
the days will be considered Part A days and charged against the beneficiarys benefit 
period.  The SNF may collect any applicable copayment amounts.  These days will be 
charged against the beneficiarys utilization as is currently done with other types of 
technical denials (i.e., late filing, late denial notices to the patient, etc.). 
 
If the SNF issues the appropriate beneficiary liability notice, and the beneficiary agrees to 
make payment either personally or through a private insurer, the days will not be charged 
towards the 100-day benefit period. 
 
50.2 - Billing When Ban on Payment Is In Effect  (Rev. 1555; Issued:  07-18-08; Effective Date:  01-01-09; Implementation Date: 01-
05-09) 
 
Beneficiaries admitted before the effective date of the denial of payment and taking 
temporary leave, whether to receive inpatient hospital care, outpatient services or as 
therapeutic leave, are not considered new admissions, and are not subject to the denial of 
payment upon return. This policy applies even if there are multiple hospitalizations and 
returns to the SNF during the period sanctions are in effect. 
 
When determining if the beneficiary was admitted prior to the imposition of the ban, the 
actual status of the beneficiary rather than the primary payor is the determining factor.  
Therefore, there may be situations where the beneficiary is a private pay patient or a dual 
eligible who was receiving Medicaid benefits prior to the imposition of the payment ban.  
If this private pay patient or dual eligible goes to the hospital for needed care, and meets 
the Medicare Part A criteria for SNF coverage upon return to the SNF, the readmission is 
exempt from the denial of payment sanction.  When billing for a readmission that is NOT 
subject to the payment ban, providers must enter occurrence span code 80, Prior Same-
SNF Stay Dates for Payment Ban Purposes, on the claim to identify the prior same-SNF 
stay dates, in addition to reporting any LOA and prior hospital stay dates, using 
occurrence span codes, that may affect the A/B MACs (A)s determination of payment 
ban exemption status.  See Chapter 25 of this manual for occurrence span code titles and 
definitions. 
 
50.2.1 - Effect of an Appeal to a DPNA on Billing During the Period the 
SNF is Subject to a DPNA 
(Rev. 1555; Issued:  07-18-08; Effective Date:  01-01-09; Implementation Date: 01-
05-09) 
 
In those situations where the SNF decides to appeal the imposition of a DPNA, it must 
still bill the program as set forth in the instructions below. 
 
50.2.2 - Provider Liability Billing Instructions 
(Rev. 1555; Issued:  07-18-08; Effective Date:  01-01-09; Implementation Date: 01-
05-09) 
 
The SNF must file a covered bill with the A/B MAC (A) using occurrence span code 77 
that indicates the facility is liable for the services in situations where the SNF failed to 
issue the proper beneficiary liability notice and any applicable copayments will be 
charged to the beneficiarys Part A benefit period.  Furthermore, the sum of all covered 
units reported on all revenue code 0022 lines should be equal to the covered days field 
less the number of provider liable days reported in the occurrence span code 77.  See 60 
of Chapter 1 in this manual for detailed instructions on nonpayment billing requirements. 
 
When the SNF is liable for the Part A stay, the SNF is required to provide all necessary 
covered Part A services, including those services such as therapies and radiology 
mandated under consolidated billing.  For example, if the beneficiary goes to the hospital  for a non-emergency chest x-ray, the SNF will be responsible for the outpatient hospital 
radiology and any ambulance charges.  In this case, the SNF may not charge the 
beneficiary or family members for any services that, in the absence of a payment 
sanction, would have been covered under the Part A PPS payment. 
 
50.2.3 - Beneficiary Liability Billing Instructions 
(Rev. 1555; Issued:  07-18-08; Effective Date:  01-01-09; Implementation Date: 01-
05-09) 
 
The SNF shall file a non-payment bill for noncovered Part A services, using condition 
code 21 that indicates beneficiary liability.  Services that would have been eligible for 
Part A benefits in the absence of sanctions cannot be billed as Part B charges.  However, 
the SNF may directly bill the beneficiary, family members or other third party insurers 
for services provided to that beneficiary. 
 
50.2.4 - Part B Billing 
(Rev. 1, 10-01-03) 
 
PM AB-01-131 
 
Facilities subject to a payment ban may continue to bill services for beneficiaries who are 
not in a Part A stay in the same way as any other SNF.  However, services that would 
have been payable to the SNF as Part A benefits in the absence of a payment sanction 
must not be billed to either the A/B MAC (A) or the A/B MAC (B) as Part B services. 
 
50.3 - Sanctions Lifted: Procedures for Beneficiaries Admitted During 
the Sanction Period 
(Rev. 1, 10-01-03) 
 
PM AB-01-131 
 
For new admissions to certified beds, Medicare payments for eligible beneficiaries should 
begin on the date the sanction is lifted.  The beneficiary must meet technical eligibility 
requirements (e.g., a 3-day hospital stay, etc.), services must be reasonable and necessary 
and the beneficiary must be receiving skilled care.  The date the sanction is lifted is 
considered the first day of the Part A stay. 
 
For Part A PPS payment purposes, the period between the actual date of admission and 
the last day the sanction was in effect should be billed as noncovered days. 
 
(See 50.3.1 below on procedures to track these noncovered days for benefit period and 
break in spell of illness calculations.  RAI requirements are discussed in 30.5.) 
 
50.3.1 - Tracking the Benefit Period 
(Rev. 1555; Issued:  07-18-08; Effective Date:  01-01-09; Implementation Date: 01-
05-09)   
SNF days during the sanction period will be used to track breaks in the spell of illness if a 
beneficiarys care in the SNF meets the skilled level of care requirements.  If the patient 
is receiving a skilled level of care the benefit period cannot end.  Therefore, it will be 
tracked in CWF. 
 
50.3.2 - Determining Whether Transfer Requirements Have Been Met 
(Rev. 1, 10-01-03) 
 
PM AB-01-131 
 
It is very important to safeguard the beneficiary while applying necessary sanctions to the 
provider.  It is certainly possible that a beneficiary may remain at a facility under sanction 
for a period of time and later transfer to a second SNF.  The 30-day transfer requirement 
will be applied in the same way it would be for a beneficiary transferring between two 
SNFs that are not under sanction.  Part A coverage will be available to the second SNF 
for all remaining days in the benefit period as long as the beneficiary: 
 
1. Had a qualifying hospital stay 
 
2. Was admitted to a Medicare-certified bed in the first (sanctioned) SNF within 30 
days of the hospital discharge, and 
 
3. Is receiving a covered level of care at the time of transfer. 
 
50.4 - Conducting Resident Assessments 
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21) 
 
The imposition of sanctions does not waive the SNFs responsibility to perform 
assessments in accordance with the clinical schedule defined in the SOM.  
Comprehensive admission assessments are still due within 14 days of admission to the 
SNF. Facility staff must also maintain the schedule for quarterly and annual assessments, 
and perform SCSAs and SCPAs when clinically appropriate. 
 
Medicare-required assessments are also necessary for all beneficiaries in the SNF whose 
stays are not subject to the payment ban.  If, during the sanction period, staff do not 
perform Medicare-required assessments for beneficiaries in covered Part A stays, no 
payment is made and the SNF must submit a claim using the HIPPS default rate code and 
an occurrence code 77 indicating provider liability, in order to ensure that the 
beneficiarys spell of illness (benefit period) is updated. 
 
Part A benefits are NOT available for beneficiaries admitted after the effective date of the 
payment ban.  Therefore, the facility is not required to perform Medicare PPS 
assessments.  Medicare payments can begin no earlier than the date the sanction is lifted.  
For Medicare PPS assessment scheduling purposes, the date the sanction is lifted should 
be considered day 1.  In this case, if the sanctions are lifted effective June 15, the  assessment reference date for the Medicare 5-day assessment must be set between June 
15 and June 22 (i.e., the eighth day of the covered stay). 
 
An SNF may choose to perform the Medicare-required assessments during the sanction 
period, but is not required to do so.  Generally, a facility should continue to do the 
Medicare PPS assessments if SNF staff believe the sanction was in error and may be 
lifted retroactively.  In this case, the SNF would be able to bill Medicare at the correct 
rate. 
 
When the SNF does not receive timely notification that a payment ban has been lifted, 
and staff is unaware of the need to start the Medicare-Required schedule (the beneficiary 
meets all applicable eligibility and coverage requirements), the SNF shall bill the 
Medicare 5-day and 14-day assessment using the HIPPS code generated by the 14-day 
OBRA required assessment.  If the SNF did not perform any assessments with an 
assessment reference date during the assessment window for the Medicare-Required 5-
day or 14-day assessment, the SNF shall bill the default rate for those covered days 
associated with the assessment.  Where the SNF did not perform an assessment with an 
ARD that fell in the applicable Medicare-Required Assessment window for the 30, 60 
and 90-day Medicare-Required Assessments it shall bill the default rate.  If the SNF did 
perform an assessment, including a SCSA, where the ARD fell in the window of a 30, 60 
or 90-day Medicare-Required Assessment (including grace days), the SNF shall bill using 
the HIPPS code generated from the assessment in accordance with the payment policies 
found in Chapter 28 of the Provider Reimbursement Manual.  The date the sanction is 
lifted is Day 1 for purposes of the Medicare assessment schedule. 
 
NOTE: In order to bill with the default code the beneficiary must at least meet the 
requirements for SNF coverage. 
 
EXAMPLE 1:  The SNF is notified on June 15th that its payment ban was lifted 
effective June 1.  The beneficiary was admitted on June 1.  The SNF 
did not perform any of the Medicare-Required Assessments.  
However, the SNF did perform the initial OBRA assessment.  The 
initial OBRA assessment shall be used to bill the 5-day Medicare-
Required Assessment for up to 14 days.  Day 15 is day 1 for purposes 
of starting the Medicare-required assessment schedule and a 5-day 
Medicare required assessment shall be performed. 
 
EXAMPLE 2:  The SNF is notified on August 15 that its payment ban was lifted on 
June 1.  The beneficiary was admitted on June 1.  The SNF did not 
perform any of the Medicare-Required Assessments.  However, the 
SNF did perform the initial OBRA Assessment.  The initial OBRA 
assessment shall be used to bill the 5-day Medicare required 
assessment and the 14-day Medicare required assessment.  The 30-day 
assessment shall be billed through day 44 at the default rate.  Day 45 is 
day 1 for purposes of starting the Medicare- required assessment 
schedule and a 5-day Medicare required assessment shall be 
performed.   
See 120.1 for the revised Medicare-required assessment schedule under the SNF PDPM 
effective October 1, 2019. 
 
50.5 - Physician Certification 
(Rev. 1, 10-01-03) 
 
PM AB-01-131 
 
The SNFs under a payment ban are still participating providers, and remain subject to 
Medicare coverage requirements.  Providers are still responsible for evaluating whether 
beneficiaries meet the Medicare Part A medical necessity and level of care requirements 
for Medicare Part A coverage, and for obtaining the required physician certifications 
even though Medicare payment cannot be made for the admission. 
 
The SNFs are required to obtain physician certifications upon notification that a sanction 
was lifted.  The date of notification will be considered day 1 when verifying the 
timeliness of the physician certification. 
 
When A/B MACs (A) process a reconsideration for a claim that was billed as a Part A 
stay, but rejected due to an incorrect application of the sanction provision, the physician 
certification is required regardless of the dates of service.  Since the provider clearly 
believed the stay was eligible for Part A payment, all Medicare coverage requirements 
must have been met. 
 
50.6 - A/B MACs (A) Responsibilities 
(Rev. 1555; Issued:  07-18-08; Effective Date:  01-01-09; Implementation Date: 01-
05-09) 
 
The A/B MACs (A) will receive notices from the CMS Regional Office when sanctions 
have been imposed or lifted and in some cases when sanctions are proposed.  The CMS 
primary objective is always to bring the facility into compliance.  In many cases, 
enforcement activity does not go beyond the notice of intent.  A/B MACs (A) shall 
initiate action only when notified that sanctions have been imposed. 
 
Upon notification that a sanction is imposed, A/B MACs (A) shall identify claims 
affected with admission dates on and after the effective date of the sanction.  
Overpayments for claims erroneously paid should be recovered and CWF properly 
updated to reflect the payment ban action.  Claims for new admissions should be denied 
from the date of admission through the last date of the sanction period. 
 
In addition, A/B MACs (A) shall determine whether claims with admission dates after the 
effective date of the sanctions qualify for readmission status, as defined in the previous 
sections, and are not subject to a payment ban.  A/B MACs (A) shall bypass local 
payment ban edits for claims that are not subject to a payment ban when dates associated 
with occurrence span code 80, Prior Same-SNF stay for payment ban purposes, indicates  the beneficiary resided in the SNF prior to the imposition of the ban.  (See 50.2 above 
for further payment ban bypassing criteria for hospitalizations and LOAs). 
 
50.7 - Retroactive Removal of Sanctions 
(Rev. 4409, Issued: 10-04- 19, Effective: 11-05-19, Implementation: 11-05-19) 
  
PM AB-01-131 
  
Occasionally, resolution between the State Agency and the SNF is reached after the 
payment ban has been imposed, and the ban is removed retroactive to its effective 
date.  If bills were denied before notice was received that the ban had been reversed, they 
should be reprocessed and paid.  When reprocessing bills, MDS assessments are needed 
to support the case-mix classification group billed. 
  
Beneficiaries and providers may request A/B MACs (A) to reopen and process bills 
denied as a result of a misunderstanding of the sanction requirements.  These reopenings 
shall be done on a request basis only, and will be limited to service dates on and after 
January 1, 1999. 
 
60 - Billing Procedures for a Composite SNF or a Change in Provider 
Number 
(Rev. 767, Issued: 12-02-05, Effective: N/A, Implementation: N/A) 
 
SNF-520, A3-3600.5 
 
A hospital with a sub-provider that meets the criteria for a composite distinct part SNF 
defined in 42 CFR 483.5 is required to use the single SNF number assigned for all claims, 
beginning with the date the provider number is effective. 
 
Where there is a change of ownership (CHOW), and the new owner refuses assignment 
of the existing provider agreement, the old owner submits all claims for periods prior to 
the CHOW using the old provider number.  The new owner submits claims for services 
rendered after the date of the CHOW using the new provider number. 
 
Also with respect to CHOWs, the SNF submits a bill with the old provider number for 
the period before the change and another with the new provider number for the period 
after the change.  The date of discharge on the first bill and the date of admission on the 
second bill are the same, which is the effective date of the new provider number.  All 
subsequent billings are submitted under the new provider number. 
 
70 - Billing for Services After Termination of Provider Agreement, or 
After Payment is Denied for New Admissions 
(Rev. 767, Issued: 12-02-05, Effective: N/A, Implementation: N/A) 
 
70.1 - General Rules 
(Rev. 767, Issued: 12-02-05, Effective: N/A, Implementation: N/A)   
A SNF whose provider agreement terminates or that is denied payment for new 
admissions as an alternative to termination for noncompliance with one or more 
requirements for participation, may only be paid for covered Part A inpatient services 
under the following conditions: 
 
Termination (Voluntary or Involuntary) 
 
  Payment can continue to be made for up to 30 days for covered Part A inpatient 
services furnished on and after the effective date of termination for beneficiaries 
who were admitted prior to the termination date. 
 
EXAMPLE:  Termination date:  9/30/86 
 
o  Beneficiary admitted:  before 9/30/86 
o  Payment can be made:  from 9/30/86, up to and including 10/29/86 
 
Denial of Payments for New Admissions (DPNA) 
 
  Payment can continue to be made for covered Part A inpatient services furnished 
on or after the effective date of denial of payments for beneficiaries who were 
admitted before the effective date of denial of payments. 
 
EXAMPLE:  Denial of payment date:  9/30/86 
 
o  Beneficiary admitted before:  9/30/86 
o  Payment can be made:  Indefinitely 
 
For detailed instructions on SNF payment bans, or denial of payment for new admission 
see IOM 100-04, Chapter 6, section 50. 
 
NOTE:  An inpatient, who goes on leave from the SNF before or after the effective date 
of denial of payments for new admissions is not considered a new admission when 
returning from leave. 
 
70.2 - Billing for Covered Services 
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiarys Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
Upon cessation of a SNFs participation in the program, or when a SNF is not receiving 
payments for new admissions, the RO is supplied with the names and Medicare  beneficiary identifiers of Medicare beneficiaries entitled to have payment made on their 
behalf for services in accordance with 80.1. 
 
SNFs no longer participating in the program, or those under a denial of payment for new 
admissions, continue to bill for covered services per 80.l.  They continue to submit no-
payment death, discharge and reduction from SNF level of care bills for Medicare 
beneficiaries admitted prior to the termination of their agreement, or prior to the denial of 
payments for new admissions. 
70.3 - Part B Billing 
(Rev. 767, Issued: 12-02-05, Effective: N/A, Implementation: N/A) 
 
Following termination of its agreement, a SNF is considered to be a nonparticipating 
provider.  An inpatient of such a SNF who has Part B coverage, but for whom Part A 
benefits have been exhausted or are otherwise not available, is entitled to payment only 
for those services that are covered in a nonparticipating institution.  Do not bill Part A 
services furnished on or after the effective date of termination. 
 
80 - Billing Related to Physicians Services 
(Rev. 2245, Issued: 06-16-11, Effective: 08-01-11, Implementation: 08-01-11) 
 
Normally physicians are responsible for billing for their own services. 
 
The services of facility-based physicians (e.g., those on a salary or percentage 
arrangement, lessors of departments, etc., whether or not they bill patients directly) 
include two distinct elements - the professional component and the provider component. 
 
The professional component of facility-based physicians services includes services 
directly related to the medical care of the individual patient.  SNFs cannot bill for the 
professional components of physician services, these must be billed under a physician 
provider number to the A/B MAC (B).  The technical component (e.g. the component 
representing the performance of the diagnostic procedure itself) of physician services 
delivered to SNF inpatients are bundled into the Part A PPS payment and not paid 
separately. 
 
A - Podiatry Services 
 
Covered professional services rendered by facility-based podiatrists to individual patients 
are covered only as physicians services under Part B.  Note that certain foot care services 
are excluded under both Part A and Part B.  Payments to podiatrists for noncovered 
services are not allowable Medicare costs regardless of whether the podiatrists 
professional services are covered under Part B. 
 
80.1 - Reassignment Limitations 
(Rev. 1, 10-01-03) 
SNF-507 
  Assigned benefits for physicians services may not be paid to anyone other than the 
physician who furnished the services, except: 
 
  To the employer of the physician who provided the service, if such physician is 
required as a condition of his employment to turn over his fee for the service to 
his employer.  (See 80.2 below.) 
 
  To a facility in which the service is provided if there is a contractual arrangement 
between the facility and the physician furnishing the service under which only the 
facility can bill for the service.  (See 80.3 below.) 
 
  To an organization, which furnishes health care through an organized health care 
delivery system (e.g., a freestanding physician clinic, or prepaid group practice 
prepayment plan) if there is a contractual arrangement between the organization 
and the physician furnishing the service under which only the organization can 
bill for the service. 
 
80.2 - Payment to Employer of Physician 
(Rev. 1, 10-01-03) 
SNF-508, SNF-510 
 
Subject to the conditions and limitations described below, payment of Part B benefits due 
a physician under assignment for services furnished in a facility may be made to the 
facility if the facility and physician have an agreement under which only the facility may 
bill and receive fees or amounts charged for the services. 
40.1 
Form CMS-855R must be completed to describe the arrangement with the facility.  This 
form and instructions for completing it can be downloaded from the CMS Forms Web 
page.  See the Medicare Program Integrity Manual for processing instructions after 
completion. 
 
The contractual arrangement between the facility and a physician may apply to all 
services the physician furnishes in the facility, or merely to a particular category of 
services that is clearly distinguishable from other categories.  The distinction between the 
categories must be consistent with proper determination of Part B reimbursement and 
may not be based on whether the patient has Medicare. 
 
While the law permits physicians to reassign to a facility the Part B benefits for the 
patient care services they perform in the facility, this exception in favor of the facility is 
intended to apply to an arrangement in which the facility obtains a significant degree of 
control or interest in the disposition of the benefits.  Under the law, Medicare benefits 
cannot be paid to a facility under terms that make the facility a mere conduit for payment 
to another person or entity. 
 
EXAMPLE 
  Under an agreement between a facility and a partnership of teaching physicians, the 
facility bills and receives payment in its name for the physician services but is required to 
turn over to the partnership all fees received, less a small deduction to defray billing 
expenses.  The partnership distributes the monies received among its physician members 
in accordance with the partnership agreement.  Since the SNF functions under the 
agreement as a mere conduit for payment to the partnership, the agreement is not an 
acceptable contractual arrangement for purposes of the exception to the prohibition on 
reassignment. 
 
80.3 - Information Necessary to Permit Payment to a Facility 
(Rev. 1, 10-01-03) 
SNF-510.1 
 
A facility may ordinarily qualify to receive Part B payment for the services of physicians 
in the facility by submitting a Form CMS-855R to its A/B MAC (A), certifying that it 
will bill for their services only as called for by its written contractual arrangements. 
 
For purposes of Medicare benefits payable for the services, this agreement may be 
terminated by either party upon written notice to the other, but such termination is not 
binding upon Medicare until two weeks after the A/B MACs (A) receives a revised Form 
CMS-855R notice of this termination. 
 
80.4 - Services Furnished Within the SNF 
(Rev. 1, 10-01-03) 
SNF-510.2 
 
The term facility is limited for purposes of furnishing services to individuals as 
inpatients, e.g., hospitals, university medical centers that own and operate hospitals, 
SNFs, nursing homes, homes for the aged, or other institutions of a similar nature.  
Physician services furnished outside the physical premises of the facility are considered 
furnished in the SNF if furnished in connection with services received by patients in the 
SNF.  For example, if SNF inpatients are taken to the private office of a neurologist for 
necessary tests such as an encephalograph, the services are considered performed in the 
SNF for billing and payment. 
 
80.5 - Billing Under Arrangements 
(Rev. 1, 10-01-03) 
SNF-510.2 
 
A provider may have others furnish certain covered items and services to their patients 
through arrangements under which receipt of payment by the provider for the services 
discharges the liability of the beneficiary or any other person to pay for the service.  In 
permitting providers to furnish services under arrangements, it is not intended that the 
provider merely serve as a billing mechanism for the other party.  Accordingly, for 
services provided under arrangements to be covered, the provider must exercise 
professional responsibility over the arranged-for services.  See the Medicare General  Information, Eligibility, and Entitlement Manual, Chapter 5, Definitions, 10.3, for 
additional discussion on services furnished under arrangement. 
 
The law is silent regarding specific terms of a SNFs payment to the outside provider or 
supplier and currently does not authorize the Medicare program to impose any 
requirements in this regard.  Thus, the issue of the outside provider or suppliers payment 
by the SNF is a private, contractual matter that must be resolved through direct 
negotiations between the parties.  However, services provided under consolidated billing 
arrangements must be provided by Medicare certified providers that are licensed to 
provide the service involved.  In addition, payment may not be made if the provider or 
supplier is subject to OIG sanctions that would prohibit Medicare payment for the service 
if the provider or supplier were billing independently. 
 
In some cases, SNFs may purchase services for their patients from a hospital under 
arrangements.  Such services may include a physician component.  When the physician 
has entered into a valid contractual arrangement with the hospital in which his/her 
services are furnished for it to bill for the services, no additional written authorization is 
needed for SNFs to bill for his/her services.  For example, where SNFs arrange to obtain 
an EKG interpretation from Hospital B, and Hospital B has a valid contractual 
arrangement with its cardiologist authorizing it to bill for his/her services, SNFs do not 
need written authorization from the cardiologist to bill Medicare for the cost of the 
services. 
 
See the Medicare Benefit Policy Manual, Chapter 8, Coverage of Extended Care (SNF) 
Services Under Hospital Insurance, 70.4, for additional information on services under 
arrangements. 
 
80.6 - Indirect Contractual Arrangement 
(Rev. 1, 10-01-03) 
SNF-510.3 
 
The necessary contractual arrangement between physicians and the facility in which they 
perform their services may exist indirectly by reason of the terms of their relationship 
with an employer and the employers contractual arrangement with the facility. 
 
EXAMPLE 
 
A professional corporation enters into a contractual arrangement with an SNF to provide 
physician services for it.  Under this arrangement, the SNF alone bills and receives 
payment for the physician services and pays the corporation a percentage of the charges.  
The corporation, in turn, employs several physicians to provide the services, and under 
the terms of their employment, is entitled to any fees payable for the services (other than 
the portion of the fees retained by the SNF).  The combination of the two arrangements - 
between the SNF and the corporation and the corporation and the physicians - constitutes 
an indirect contractual arrangement between the SNF and the physicians.  For the SNF to 
bill and receive payment for the physician services furnished in the SNF, the SNF must 
also enter into a direct contractual arrangement with the physicians for this purpose.   
80.7 - Establishing That a SNF Qualifies to Receive Part B Payment on 
the Basis of Reassignment 
(Rev. 1, 10-01-03) 
SNF-512 
 
A SNF wishing to receive Part B payment as a reassignee of one or more physicians must 
furnish the A/B MAC (B) sufficient information to establish clearly that it qualifies or 
does not qualify to receive payment for their services.  Where there is any doubt that a 
SNF qualifies as a reassignee, A/B MACs (B) will obtain additional evidence. 
 
In some cases, a SNF may qualify to receive payment for the services of a physician both 
as the employer of the physician and as the facility in which the services are performed.  
As soon as it is determined that a SNF can qualify on either basis, no further development 
is undertaken with respect to that physician or to other physicians having the same status, 
and reassigned claims submitted by the SNF for services furnished by those physicians 
are honored.  However, where other physicians have, or appear to have different status, 
further development is required.  It is possible in some instances that a determination is 
made that Part B payment can be made only to the physician himself. 
 
Where the SNF qualifies as a reassignee, it assumes the same liability for any 
overpayments that it may receive as a reassignee as the physician would have had if the 
payment had been made to him/her. 
 
90 - Medicare Advantage (MA) Beneficiaries 
(Rev. 1252, Issued:  05-25-07; Effective:  10-01-06; Implementation:  08-27-07) 
 
For billing to MA plans, SNFs follow the requirements of the agreement they have with 
the plans.  In cases where the patient may have enrolled or disenrolled from the plans 
during the billing period, the SNF will split the bill and send the plans portion to it and 
the remaining portion to the A/B MAC (A). 
 
90.1 - Beneficiaries Disenrolled from MA Plans 
(Rev. 1618, Issued: 10-24-08, Effective: 04-01-09; Implementation: 04-06-09) 
 
If a beneficiary voluntarily or involuntarily dis-enrolls from a risk MA plan while an 
inpatient of an SNF and converts to original Medicare (i.e., fee for service) the 
requirement for a three day hospital stay will be waived if the beneficiary meets the level 
of care criteria found in 42 CFR 409, Subpart D, up through the effective date of dis-
enrollment.  The beneficiary will then be eligible for the number of days that remain out 
of the 100 day SNF benefit for that particular SNF stay minus those days that would have 
been covered by the program under original Medicare while the beneficiary was enrolled 
in the risk MA plan.  However, in cases where the beneficiary disenrolls from a risk MA 
plan after discharge from the SNF, and then is readmitted to the SNF under the 30 day 
rule, all requirements for original Medicare (i.e., fee for service), including the 3-day  hospital stay must be met.  Rules regarding cost sharing apply to these cases.  That is, 
providers may only charge beneficiaries for SNF coinsurance amounts. 
 
If the beneficiary voluntarily disenrolls from a risk MA plan and converts to original 
Medicare (i.e., fee for service) before admission to a SNF then the beneficiary must meet 
all original Medicare requirements for a SNF stay, including that of a three day inpatient 
hospital stay. 
 
SNFs submit all applicable fee-for-service inpatient SNF claims with condition code 58 
to indicate a patient was disenrolled from an MA plan and the 3-day prior stay 
requirement was not met.  Claims with condition code 58 will not require the 3-day prior 
inpatient hospital stay.  The A/B MAC (A) must use CWF files to validate the beneficiary 
was enrolled in an MA organization upon admission to the SNF and that the MA 
enrollment period ended prior to the from date on the claim.  The A/B MAC (A) does 
not need to verify that the MA plan was the one that terminated. 
 
90.2 - Medicare Billing Requirements for Beneficiaries Enrolled in MA 
Plans 
(Rev.4491, Issued: 01-09- 20, Effective: 04-01-20, Implementation: 04-06-20) 
 
If a beneficiary chooses an MA plan as his or her form of Medicare, he/she cannot look to 
traditional fee for service Medicare to pay the claim if the MA plan denies coverage.  
SNF providers shall apply the following policies to MA beneficiaries who are admitted to a 
SNF:  
 If the SNF is non-participating with the plan, the beneficiary must be notified of his or her 
status because he/she MAY be private pay in this circumstance, depending upon the type of 
MA plan in which he/she is enrolled;  
 
 If the SNF is participating with the plan, pre-approve the SNF stay with the plan;  
 
 If the plan denies coverage, appeal to the plan, not to the fee for service FI;  
 
 Count the number of days paid by the plan as Part A days used (this IS the beneficiarys 
100 days of Medicare SNF benefits);  
 
 Submit a claim to the fee for service A/B MAC (A) to subtract benefit days from the 
CWF records. (Note: The plans do not send claims to CWF for SNF stays). Failure to send a 
claim to the A/B MAC (A) will inaccurately show days available.  
 
 If a beneficiary no longer requires skilled care under the MA plan the SNF may discharge 
the patient using a patient status code 04. No- payment bills are not required for beneficiaries 
that are receiving non-skilled care and are enrolled in an MA plan. If the beneficiary again 
requires skilled care after a period of non-skilled care, the provider should begin a new 
admission claim for Medicare to continue the spell of illness.  
 
Billing Requirements    Submit covered claims and include a HIPPS code (use default code AAA00 prior to 
10/1/2019 and ZZZZZ after 10/1/2019) if no assessment was done), room and board charges 
and condition code 04. 
 
 
NOTE: If the beneficiary drops his or her MA plan participation during their SNF stay, the 
beneficiary is entitled to coverage under Medicare FFS for the number of days available that 
remain out of the 100 days available under the SNF benefit.  
 
 
100 - Part A SNF PPS for Hospital Swing Bed Facilities 
(Rev. 1, 10-01-03) 
PM A-02-016 
 
Section 4432(a) of the Balanced Budget Act (BBA) of 1997 specifies that swing bed 
facilities must be incorporated into Part A SNF PPS by the end of the statutory transition 
period.  Effective with cost reporting periods beginning on or after July 1, 2002, swing 
bed bills are not paid on the cost-based method, but rather on the basis of the Part A SNF 
PPS.  These payment rates cover all payment for furnishing covered swing bed extended 
care services (routine, ancillary, and capital-related costs) other than approved 
educational activities as defined in 42 CFR 413.85. 
 
Part A SNF PPS applies to short-term hospitals, long-term care hospitals, and 
rehabilitation hospitals that have Medicare swing bed agreements.  CAHs with swing 
beds are exempt from the Part A SNF PPS, and are not affected by these instructions. 
 
The Part A PPS is phased in based on each swing bed hospitals fiscal year.  The 
transition to Part A PPS is effective with the start of the providers first cost reporting 
period that begins on or after July 1, 2002.  Consequently, billing for all beneficiaries in a 
swing bed must be split at the end of the providers fiscal year.  A new bill is created for 
beneficiaries remaining in the facility at the start of the new fiscal year.  The bill must be 
prepared under the Part A PPS claim guidelines described in this chapter and in Chapter 
1, General Billing Requirements.  Payment is made according to the instructions for 
SNFs under Part A PPS found in the Medicare Provider Reimbursement Manual. 
 
Providers of swing bed services submit Part A inpatient claims using TOB 18X. 
 
The swing bed program does not include an inpatient Part B benefit.  For beneficiaries 
who continue to receive extended care services after the end of a Part A stay (e.g., 
benefits exhausted, not receiving a skilled level of care, etc.), ancillary services may be 
billed under the hospital as inpatient Part B services. 
 
If the beneficiary remains a resident in the swing bed facility after the end of the Part A 
stay, the hospital may submit a claim to the A/B MAC (A) for those inpatient services 
covered by Part B using TOB 12X.  The beneficiary would be eligible for the same 
benefits available to a hospital inpatient in a Part B stay.  The hospital provider of SNF  level swing bed services must also file a Part A nonpayment bill monthly using the 
appropriate nonpayment code. 
 
For Part A PPS purposes, A/B MACs (A) assign swing bed hospitals to provider type 38 
on their Provider-Specific File.  Swing bed providers will be paid at 100 percent of the 
Federal rate.  Swing bed claims will be paid using the actual MSA code (based on county 
codes), and the related rural or urban rate tables.  A/B MACs (A) must set the Federal 
PPS Blend Indicator in the Provider-Specific file to 4.  The CMI ADJ CPD field should 
be blank. 
 
Unless exceptions are noted, instructions applicable to SNFs are also applicable to swing 
bed providers e.g., demand bills, spell of illness, covered and noncovered days, 
nonpayment bills, and adjustment bills. 
 
100.1 - Swing Bed Services Not Included in the Part A PPS Rate 
(Rev. 4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19) 
PM A-02-016 
 
For their SNF-level inpatients, rural (non-CAH) swing bed hospitals must submit all 
services that are not specifically excluded from consolidated billing on their Part A swing 
bed bill (TOB 18x). However, they are eligible for additional payment outside the 
bundled SNF PPS rate for those services that are excluded from the SNF Part A 
consolidated billing requirements.  Further, because the swing bed hospital itself still 
remains subject to the hospital bundling requirements specified in 1862(a)(14) of the 
Act and in 42 CFR 411.15(m), it retains the Medicare billing responsibility for any 
excluded services to which the hospital bundling provision applies.  Accordingly, it 
would use a separate inpatient Part B claim to bill for such services (see 10.2 of this 
chapter).   
 
As noted above, if a swing bed hospital furnishes a service or supply to a beneficiary 
receiving SNF-level services, which is excluded from the Part A PPS rate, the swing bed 
hospital may submit a separate bill to the A/B MAC (A) for the SNF PPS-excluded 
service.  This bill must use TOB 13x with all appropriate revenue codes, HCPCS codes, 
and line item date of service billing information and will be paid as inpatient Part B 
services under the Outpatient Prospective Payment System (OPPS).  (By contrast, those 
services bundled into the SNF PPS rate may not be billed separately, and must all be 
included on the Part A swing bed bill (TOB 18x).)  A list of services that are excluded 
from the SNF PPS rate is found in 20.1 - 20.4 above. 
 
Likewise, swing bed hospitals may file bills with the A/B MAC (A) for Part B Ancillary 
services furnished to beneficiaries who are not in a Part A PPS swing bed stay.  Such 
claims are billed as inpatient Part B services, and are paid under the OPPS. 
  110 - A/B MAC (B)/DME MAC Claims Processing for Consolidated 
Billing for Physician and Non-Physician Practitioner Services Rendered 
to Beneficiaries in a SNF Part A Stay 
(Rev. 1757, Issued: 06-19-09, Effective: 07-20-09, Implementation: 07-20-09) 
 
For an overview of SNF consolidated billing, including types of facilities and services 
subject to consolidated billing, see sections 10 and 20. 
 
110.1 - Correct Place of Service (POS) Code for SNF Claims 
(Rev. 76, 02-06-04) 
 
Place of Service (POS) code 31 should be used with services for patients in a Part A 
covered stay and POS code 32 should be used with services for beneficiaries in a 
noncovered stay.  A/B MACs (B) should adjust their prepayment procedure edits as 
appropriate. 
 
110.2 - CWF Edits 
(Rev. 76, 02-06-04) 
 
The following edits have been implemented in CWF. 
 
110.2.1 - Reject and Unsolicited Response Edits 
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiarys Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
A.  Reject Edits 
 
When CWF receives a bill from the SNF that shows that a beneficiary became a resident 
of a SNF, that SNF stay is posted to history.  Effective April 2002, for claims processed 
and adjusted with dates of service on or after April 1, 2001, CWF will apply the reject 
edits to any claims received after the SNF stay is posted that have dates of service during 
the periods the beneficiary is shown to have been a resident of the SNF based on that first 
SNF bill.  These claims can be correctly rejected since it will be clear that the beneficiary 
was in the SNF during those spans that were shown on the SNF claim.  This process will 
repeat when the next SNF bill is received.  The process will continue until CWF posts a 
discharge date, date of death, or the covered number of SNF days has been used. 
 
Based on the CWF line item rejects, A/B MACs (B)/DME MACs must deny assigned 
and unassigned services they have been billed that should have been consolidated and 
paid by the SNF and/or billed to the A/B MAC (A).  Appeals rights must be offered on  all denials.  Shared systems must develop, and along with A/B MACs (B)/DME MACs 
must implement, an automated resolution process whereby when they receive a reject 
from CWF, they must pay those services correctly billed and only deny those services on 
the claim incorrectly billed to them. 
 
B. Unsolicited Response Edits 
 
Effective July 1, 2002, CWF implemented the unsolicited response edit based on the 
same coding files made available for the reject edits.  Upon receipt of a Part A SNF claim 
at CWF, CWF searches paid claims history and compares the period between the SNF 
from and through dates to the line item service dates of the claims in history.  It then 
identifies any services within the dates of the SNF stay that should have been subject to 
consolidated billing and should not have been separately paid by the A/B MAC (B)/DME 
MAC. 
 
The CWF generates an unsolicited response, with a trailer that contains the identifying 
information regarding the claim subject to consolidated billing and a new trailer 
containing line item specific information that identifies all the individual services on that 
claim that fall within the SNF period.  The unsolicited response provides all necessary 
information to identify the claim, including Document Control Number, Medicare 
beneficiary identifier, beneficiary name, date of birth, and beneficiary sex.  CWF 
electronically transmits this unsolicited response to the A/B MAC (B)/DME MAC that 
originally processed the claim with consolidated services.  These unsolicited responses 
are included in the CWF response file.  The unsolicited responses in that file for claims to 
be adjusted for consolidated billing are identified with a unique transaction identifier.  
The previously paid claim is not canceled and remains on CWF paid claims history, 
pending subsequent adjustment. 
 
Upon receipt of the unsolicited response, the shared system software reads the line item 
information in the new trailer for each claim and performs an automated adjustment to 
each claim.  Services subject to consolidated billing must be denied at the line level.  The 
adjusted claims must then be returned to CWF, so that the claim on CWF paid claims 
history is replaced with the adjusted record.  A/B MACs (B)/DME MACs must return the 
claims with entry code 5.  Both the covered and the non-covered services must be 
returned to CWF on the adjustment claim. 
 
When CWF adjusts the claim on history, the deductible is updated on the beneficiarys 
file and the corrected deductible information is returned to the A/B MAC (B)/DME MAC 
in trailer 11.  To recover any monies due back to Medicare resulting from these denials, 
A/B MACs (B)/DME MACs must follow the criteria in current overpayment recovery for 
the policy guidelines for furnishing demand letters and granting appeals rights. 
 
In cases where all services on the claim are identified in CWF as subject to consolidated 
billing, the claim is adjusted by the standard system to line item deny all the services on 
the claim.  These fully non-covered claims must be returned to CWF, in order to reflect 
the denial actions in CWF paid claims history and to update the information in CMSs  national claims history file.  A/B MAC (B)/DME MAC systems must employ existing 
processes for the submission of fully non-covered claims. 
 
110.2.2 - A/B Crossover Edits 
(Rev. 1757, Issued: 06-19-09, Effective: 07-20-09, Implementation: 07-20-09) 
 
Effective April 1, 2002, CWF implemented the following crossover edits for A/B MAC 
(B) submitted claims.  Automated processes were implemented for the resolution of these 
edits based on the codes returned in the trailers from CWF. 
 
A. Edits 7258 and 7259 - Part B Physical Therapy Claim Against an Inpatient SNF 
21x and Inpatient Part B 22x Claim 
 
Reject if an A/B MAC (B) claim is received containing physical therapy (type of service 
of W), occupational therapy, or speech-language pathology and From/Thru Dates overlap 
or are within the From/Thru Dates on an SNF inpatient claim (21x) or an inpatient Part B 
claim (22x). 
 
Use separate error codes where (1) dates are within (A/B MAC (B) will reject claim) or 
(2) where dates overlap (A/B MAC (B) will automate a separate denial message to 
provider). 
 
Bypass the edit in the following situations: 
 
  The 21x or 22x type of bill contains a cancel date. 
 
  The incoming claim from date equals the SNF 21x or 22x history claim discharge 
date or incoming through date equals the SNF 21x or 22x history claim 
admission date. 
 
Effective for claims with dates of service on or after April 1, 2001, CWF implemented 
revisions on January 2, 2008 to bypass the edits 7258 and 7259 when a therapy claim 
with a date of service on or after April 1, 2001 is submitted and the date of service is 
within the From/Thru dates of an occurrence Span code date of 74 reported on a SNF 
inpatient claim 21x in history.  This will allow for services to be separately payable 
outside of SNF consolidated billing during non-covered periods in the SNF. 
 
Effective for claims with dates of service on or after April 1, 2001, CWF implemented 
revisions on April 7, 2008 to modify the existing therapy edit for Part B claims 
processing for non-covered SNF stays to read claims history to look for a 21x (SNF 
Inpatient) bill type that contains an Occurrence Code 22 (Date Active Care Ended) and a 
Patient Status Code 30 (Still patient or expected to return for outpatient services) where 
there is no subsequent 21x (SNF inpatient) bill type discharge claim from the same 
provider.  As therapy services provided in a SNF must be consolidated when a 
beneficiary is in either a covered or non-covered stay, CWF will reject claims with dates 
of service after the posted SNF claim containing Occurrence Code 22 (Date Active Care 
Ended) and Patient Status 30 (Still patient or expected to return for outpatient services)  until a 21x (SNF inpatient) bill type discharge claim is processed.  The entity furnishing 
the therapy services must look to the SNF for reimbursement rather than the A/B MAC 
(A) or (B).  For claims processed on or after January 5, 2009, this edit shall no longer be 
functional.  A/B MACs (A) and (B) shall re-open and-re-process claims previously 
denied due to this edit when brought to their attention should they determine that the 
beneficiary was not in a SNF stay during the period the therapy service was 
rendered. 
 
B. Edits 7260 and 7261 - Part B Claim Without Therapy Against an Inpatient SNF 
 
Reject if a Part B claim is received with From/Thru Dates overlapping or are within the 
From/Thru Dates on an SNF Inpatient claim (21x).  If the SNF 21x claim on history has 
patient status 30 and occurrence code 22 (Date Active Care Ended), use occurrence 22 
date instead of the through date. 
 
Use separate error codes where (1) dates are within (A/B MAC (B) will reject claim); or 
(2) where dates overlap (A/B MAC (B) will automate a separate denial message to 
provider). 
 
Bypass the edit in the following situations: 
 
  The 21x history claim contains a cancel date. 
 
  The incoming A/B MAC (B) claim from date equals the SNF 21x history claim 
discharge date.  The incoming A/B MAC (B) claim through date equals the SNF 
21x history claim admission date. 
 
  A diagnosis code in any position on the incoming claim is for renal disease. 
 
  The A/B MAC (B) claim contains ambulance codes per the files supplied to CWF 
in the annual and quarterly updates with modifiers other than N (SNF) in both the 
origin and destination on the same claim. 
 
  The A/B MAC (B) claim is a CANCEL ONLY (Action Code 4) claim. 
 
  The A/B MAC (B) claim is denied. 
 
  The A/B MAC (B) service has a Payment Process Indicator other than A 
(allowed). 
 
  The A/B MAC (B) claim contains only separately payable services per the files 
supplied to CWF in the annual and quarterly updates. 
 
Effective for claims with dates of service on or after April 1, 2001, CWF implemented 
revisions on January 2, 2008 to bypass the edits 7260 and 7261 when a claim with a date 
of service on or after April 1, 2001 is submitted and the date of service is within the  From/Thru dates with an occurrence Span code date of 74, 76, 77, 79, or M1 reported on 
a SNF inpatient claim 21x in history or the date of service is greater than the occurrence 
date on a SNF inpatient claim 21x in history with an occurrence code date of A3, B3, or 
C3.  This will allow for services to be separately payable outside of SNF consolidated 
billing during non-covered periods in the SNF. 
 
110.2.3 - Duplicate Edits 
(Rev. 1757, Issued: 06-19-09, Effective: 07-20-09, Implementation: 07-20-09) 
 
Effective April 1, 2002, CWF implemented the following duplicate edits for A/B MAC 
(B) submitted claims. 
 
A. Edit 7253 - Part B Ambulance Claim Against an Outpatient Part B SNF 
Ambulance Claim on History 
 
Reject if a Part B claim is received with ambulance codes per the files supplied to CWF 
in the annual and quarterly updates and the Date of Service equals the Date of Service on 
an outpatient Part B SNF (23x) claim with revenue code 54x (ambulance). 
 
Bypass the edit if either the incoming or history claim contains any of the following 
situations: 
 
  The claim is a CANCEL ONLY (Action Code 4) claim. 
  The claim is denied. 
  The incoming claim payment process indicator is other than A (allowed). 
 
B. Edit 7257 - A/B MAC (B) or DME MAC or A/B MAC (A) Part B Claim Against 
An Inpatient B SNF (22x) Claim on History 
 
Reject as a duplicate claim if an A/B MAC (B) or DME MAC Part B claim or A/B MAC 
(A) Part B claim (12x, 13x, 14x, 23x, 33x, 71x, 73x, 74x, 75x, 76x, 83x or 85x) is 
received containing date of service, HCPCS code and modifier if present, equal to the 
date of service, HCPCS code and modifier, if present, on an inpatient Part B SNF (221, 
222, 223, 224 or 225) claim. 
 
Bypass the edit if either the incoming or history claim contains any of the following 
situations: 
 
  The claim is a CANCEL ONLY (Action Code 4) claim. 
  The claim is denied. 
  HCPCS code is not present on the A/B MAC (A) claim. 
  The A/B MAC (B) Part B claim payment process indicator is other than A 
(allowed). 
  For the A/B MAC (B)/DME MAC claim only, the Part B claim contains only 
separately payable services per the files supplied to CWF in the annual and 
quarterly updates.   
110.2.4 - Edit for Ambulance Services 
(Rev. 1757, Issued: 06-19-09, Effective: 07-20-09, Implementation: 07-20-09) 
 
When a medically necessary transport from one SNF to another SNF occurs when the 
beneficiary is discharged from the first SNF and admitted to the second, this transport is 
included in consolidated billing.  The first SNF is responsible for the ambulance service 
and the cost is included in the Part A rate.  It is not separately billable.  CWF will reject 
these services to the A/B MAC (B).  The A/B MAC (B) must deny the service with 
appeals rights. 
 
Effective for claims with dates of service on or after April 1, 2001, CWF implemented 
revisions on January 2, 2008 to bypass edit 7275 when a claim with a date of service on 
or after April 1, 2001 is submitted and the date of service is within the From/Thru dates 
with an occurrence Span code date of 74, 76, 77, 79, or M1 reported on a SNF inpatient 
claim 21x in history or the date of service is greater than the occurrence date on a SNF 
inpatient claim 21x in history with an occurrence code date of A3, B3, or C3.  This will 
allow for services to be separately payable outside of SNF consolidated billing during 
non-covered periods in the SNF. 
 
110.2.5 - Edit for Clinical Social Workers (CSWs) 
(Rev. 3481, Issued: 03-18-16. Effective: 06-20-16, Implementation: 06-20-16) 
 
Per the Balanced Budget Act, services provided by CSWs to beneficiaries in a Part A 
SNF stay may not be billed separately to the A/B MAC (B).  Payment for these services 
is included in the prospective payment rate paid to the SNF by the A/B MAC (A).  
Though the policy was in effect since April 1, 2001, there were no corresponding edits. 
With the April 2003 release, CWF implemented a new SNF consolidated billing edit to 
prevent payment to CSWs for services rendered to beneficiaries in a Part A SNF stay. 
 
Effective April 1, 2003, CWF established the new edit 7269 for services rendered to these 
beneficiaries with dates of service on or after April 1, 2001, for claims received on or 
after April 1, 2003.  Once CWF determines that a beneficiary is in a Part A stay, prior to 
applying the edits that review procedure codes to determine if payment should be 
allowed, CWF will review the performing provider type of the submitting entity.  If the 
performing provider type is 80, CWF will reject the claim to the A/B MAC (B) or return 
an unsolicited response with new error code 7269.  The A/B MAC (B) will then take the 
same adjustment and recovery action as for other rejects and unsolicited responses. 
 
When A/B MACs (B) receive the new reject code, they must deny the claim and use the 
following RA and MSN messages. 
 
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: N121 
MSN: 13.10 
 
Effective for claims with dates of service on or after April 1, 2001, CWF implemented 
revisions on January 2, 2008 to bypass edit 7269 when a claim with a date of service on 
or after April 1, 2001 is submitted and the date of service is within the From/Thru dates 
with an occurrence Span code date of 74, 76, 77, 79, or M1 reported on a SNF inpatient 
claim 21x in history or the date of service is greater than the occurrence date on a SNF 
inpatient claim 21x in history with an occurrence code date of A3, B3, or C3.  This will 
allow for services to be separately payable outside of SNF consolidated billing during 
non-covered periods in the SNF. 
 
110.2.6 - Edit for Therapy Services Separately Payable When Furnished 
by a Physician 
(Rev. 1757, Issued: 06-19-09, Effective: 07-20-09, Implementation: 07-20-09) 
 
A number of therapy services are considered separately payable when provided by a 
physician and shall be paid separately by the A/B MAC (B).  However, these services are 
considered therapy when provided by a physical or occupational therapist and are subject 
to consolidated billing. 
 
Effective for claims with dates of service on or after July 1, 2004, edits will be 
implemented in the claims processing system to correctly process claims for these 
services.  A complete list of these services can be found on the CMS website at 
https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/. 
 
110.2.7 - Edit to Prevent Payment of Facility Fees for Services Billed by 
an Ambulatory Surgical Center (ASC) when Rendered to a Beneficiary 
in a Part A Stay 
(Rev. 1911; Issued:  02-05-10; Effective Date:  01-01-08; Implementation Date:  07-
06-10) 
 
The Balanced Budget Act (BBA) of 1997 required the implementation of a SNF 
prospective payment system and the consolidated billing of services provided to residents 
of the SNF.  Facility services provided by a freestanding non-hospital ASC are included 
under the SNF CB provisions.  This edit will prevent payment of those facility services 
when provided in an ASC to a beneficiary in a Part A SNF CB stay. 
 
Effective for claims with dates of service on or after January 1, 2008 that are processed 
on or after July 6, 2010, when CWF receives a claim for a facility service from an ASC 
that is enrolled as a provider specialty type 49, and the service has a Type of Service F, 
and the patient is in a Part A SNF stay, it shall notify the A/B MACs (B) that they shall 
reject the claim line for the service(s).  It shall send the same trailer that is currently sent 
for services subject to SNF consolidated billing.  (The services subject to this editing will 
also appear on the ASC Fee schedule.)   
Also, when CWF receives a Part A SNF claim, it shall also notify A/B MACs (A), (B), or 
(HHH), and DME MACs through an unsolicited response of any facility services as 
described above that were incorrectly paid.  MACs shall follow current processes to 
recoup any overpayments. 
 
A/B MACs (A), (B), (HHH), or DME MACs shall return the same messages found in 
Section 110.2.1C. 
 
110.3 - CWF Override Codes 
(Rev. 1757, Issued: 06-19-09, Effective: 07-20-09, Implementation: 07-20-09) 
 
A CWF override code has been developed for A/B MAC (B) or DME MAC use where, 
in the course of pursuing a reconsideration, a provider or supplier may bring to the 
attention of the A/B MAC (B) a situation where services on a claim have been denied, 
but should actually be allowed to be paid through the A/B MAC (B)/DME MAC.  At the 
A/B MAC (B)/DME MACs discretion, to allow that claim to process through CWF to 
payment, enter a 2 in the SNF consolidated billing override field. 
 
110.4 - Coding Files and Updates 
(Rev. 1757, Issued: 06-19-09, Effective: 07-20-09, Implementation: 07-20-09) 
 
To correspond with the annual and quarterly coding and payment updates, CWF will be 
provided with files of codes that are not included in consolidated billing and can be paid 
through the A/B MAC (B) or DME MAC.  These codes are available for informational 
purposes on the CMS Web site at https://www.cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/SNFPPS/ConsolidatedBilling.html.  Changes in designation of codes 
from excluded to included (or vice versa) in consolidated billing will be considered 
corrections to align the codes with policy as opposed to changes in policy.  Newly 
established Healthcare Common Procedure Coding System codes will be added to CWF 
edits to allow A/B MACs (B)/DME MACs to make appropriate payments. 
 
110.4.1 - Annual Update Process 
(Rev. 2802, Issued: 10-25-13, Effective: 01-01-14, Implementation: 01-06-14) 
 
Barring any delay in the Medicare Physician Fee Schedule, CMS will provide the new 
code files to CWF by November 1.  Should this date change, CWF will be notified 
through the appropriate mechanism.  All future updates will be submitted via a Recurring 
Update Notification form.  These Recurring Update Notifications also describe how the 
changes will be implemented. 
 
CWF will be provided with 4 coding files (Physician Services, Professional Component 
of Physician Services to be Submitted with the 26 Modifier, Ambulance, and Therapy) 
that are effective based on dates of service January 1 through December 31 for that year.  
New files shall be provided for each calendar year.  Quarterly updates to the four files 
will continue as usual.   
A/B MACs (B)/DME MACs must continue to respond to rejects and unsolicited 
responses received from CWF per current methodology. 
 
A/B MACs (B)/DME MACs must reopen and reprocess any claims brought to their 
attention for services that prior to this update were mistakenly considered to be subject to 
consolidated billing and therefore, not separately payable.  A/B MACs (B)/DME MACs 
need not search claims history to identify these claims. 
 
Prior to January 1 of each year, new codes files will be posted to the CMS Web site at.  
https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/.  Should this date 
change, A/B MACs (B)/DME MACs will be notified through the appropriate mechanism. 
 
Coding changes throughout the year may also be made as necessary through a quarterly 
update process. 
 
As soon as the new code files are posted to the CMS Web site, through their Web sites 
and list serves, A/B MACs (B)/DME MACs must notify physician, non-physician 
practitioners, and suppliers of the availability of the files. 
 
120 - Skilled Nursing Facility (SNF) Patient Driven Payment Model 
(PDPM) 
(Rev. 4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19) 
 
SNFs billing on Type of Bill (TOB) 21X and rural hospital (non-CAH) swing-bed 
providers billing on TOB 18X (subject to SNF PPS), will be subject to these 
requirements. Currently, under the SNF PPS, revenue code 0022 indicates that this claim 
is being paid under the SNF PPS. This revenue code can appear on a claim as often as 
necessary to indicate different Health Insurance Prospective Payment System (HIPPS) 
Rate Code(s) and assessment periods. The HCPCS/Rates field must contain a 5-digit 
HIPPS Code. Under the previous case-mix classification model, the Resource 
Utilization Groups, version 4 (RUG-IV), the first three positions of the code contained 
the RUG group, and the last two positions of the code contained a 2-digit assessment 
indicator (AI) code. 
 
120.1 - HIPPS Updates and Structure Changes 
(Rev. 4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19) 
 
Under PDPM, the HIPPS code is structured differently, as a result of there being five 
case-mix adjusted rate components under the revised model. The first position represents 
the Physical and Occupational Therapy case-mix group. The second position represents 
the Speech-Language Pathology case-mix group. The third character represents the 
nursing case-mix group. The fourth character represents the Non-Therapy Ancillary 
(NTA) case-mix group. The fifth character represents the AI code. CMS would note that 
this also affects the number of potentially valid HIPPS codes under PDPM, as compared 
to RUG-IV.   
The PPS assessment schedule under PDPM is also significantly different from that used 
under RUG-IV. The only assessments under PDPM that would produce a HIPPS code 
would be the initial Medicare (5-day) PPS assessment, which follows the same 
schedule as under the previous RUG-IV model, and the optional Interim Payment 
Assessment (IPA), which may be completed at any point during a PPS stay. 
 
The initial SNF PDPM HIPPS Codes can be found online at: 
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes.html 
 
Note: AAA00 default will be replaced with ZZZZZ effective October 1, 2019. 
 
120.2 - Interrupted Stay Policy 
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21) 
 
PDPM includes an interrupted stay policy, which would combine multiple SNF stays into 
a single stay in cases where the patients discharge and readmission occurs within a 
prescribed window (i.e., interruption window), similar to that which exists currently in 
many other Medicare inpatient facilities.  Specifically, if a patient in a covered Part A 
SNF stay is discharged from the SNF but returns to the SNF no later than 11:59pm of the 
third consecutive calendar day after having left Part A coverage, then this would be 
considered a continuation of the same SNF stay. In such cases, no new patient 
assessments are required and the variable per diem adjustment is not reset.  If the patient 
returns to the same SNF outside the interruption window, or returns to a different SNF, 
then this would be considered a new stay.  
 
The interruption window begins on the first non-covered day following a Part A-covered 
SNF stay and ends at 11:59pm on the third consecutive non-covered day.  The first non-
covered day in this context may be different depending on whether the patient actually 
leaves the facility or simply leaves Part A coverage.  Specifically, if the patient physically 
leaves the SNF, the first day of the interruption window would be the day of departure 
itself, whereas if the patient simply discontinues Part A coverage but remains in the SNF, 
the first day of the interruption window would be the day following the final day of Part 
A coverage. 
 
Specifying the endpoint of the interruption windows third day as occurring at 11:59 pm 
rather than at midnight is consistent with the regulations at 42 CFR 411.15(p)(3)(iv), 
which define a beneficiarys SNF resident status for consolidated billing purposes as 
ending whenever he or she is formally discharged (or otherwise departs) from the SNF, 
unless he or she is readmitted (or returns) to that or another SNF . . . before the 
following midnight (emphasis added). See 10.1 of this chapter, and also see 20.1 in 
the Medicare Benefit Policy Manual, Chapter 3, which specifies that in counting inpatient 
days, . . . a day begins at midnight and ends 24 hours later.  However, unlike similar 
interrupted stay policies under some of the other prospective payment systems, the SNF 
interrupted stay policy is not used in determining whether bundling would apply to 
services furnished during the interruption.  That determination would instead continue to  follow the longstanding set of rules under 42 CFR 411.15(p)(3) regarding SNF resident 
status for consolidated billing purposes (see 10ff.). 
 
The day of discharge (as noted above, this date could be different if the patient leaves the 
facility or simply leaves Part A coverage) is the FROM date and the last day the patient is 
not in the SNF at midnight is the THROUGH date.  Occurrence span code 74 should be 
reported for each interruption of more than ONE day. 
 
The interrupted stay would be recorded on the claim in the same manner as is done for 
the IRF PPS, and as further discussed in the examples below. 
 
Examples: 
1) Patient is admitted to SNF on 11/07/19 and is in a covered Part A stay. Patient is 
discharged from the SNF and admitted to the hospital on 11/20/19.  Patient is readmitted 
to the same SNF on 11/25/19 and is in a covered Part A stay.  The readmission is a new 
stay because more than 3 days have passed from the date the patient was discharged from 
the SNF and the date the patient was readmitted to the same SNF. 
 
New stay 
Assessment Schedule: Reset; stay begins with new 5-day assessment. 
Variable Per Diem (VPD): Reset: stay begins on Day 1 of VPD Schedule. 
 
2) Patient is admitted to SNF on 11/07/19 and in a covered Part A stay.  The patient is 
discharged from Part A on 11/20/19 but remains in the facility.  The patient returns to a 
covered Part A stay on 11/22/19.  This is a continuation of a previous stay because the 
patient returned to a covered Part A stay within 3 days of being discharged from a 
covered Part A stay. 
 
Continuation of previous stay 
Assessment Schedule: No PPS assessments required, IPA optional 
VPD: Continues from Day 14 (Day of Part A Discharge). 
 
Billing Example: Patient is admitted to SNF on 10/1/2019 and discharged to home on 
12/25/2019, with an interrupted stay to an IPPS on 10/20/2019-10/22/2019. This was an 
admission to an IPPS on 10/20/2019-10/22/2019. 
 
10/1/2019  10/31/2019 first interim claim,  
Claim must be billed with occurrence span code 74 and occurrence span dates 10/20  
10/21/2019 to represent the interrupted stay, 
11/1/2019  11/30/2019 second interim claim,  
12/1/2019  12/25/2019 final interim claim,  
(Occurrence span code 74 only appears on the claim in which its dates fall within the 
statement covers period  in this example only on October claim). 
 
  Accommodation revenue code 018x is reported during the interrupted stay and is 
when the beneficiary is not present at the midnight census taking time. 
  Occurrence span code 74 and date range for the interruption.   
Days for the interruption shall be reported as non-covered, not to exceed 3 days or it will 
be considered a new admission. 
 
On the SNF Medicare bill, the presence of occurrence span code 74 indicates an 
interrupted stay has occurred.  Report occurrence span code 74 with the FROM and 
THROUGH dates of the interruption in the stay.  The day of discharge from the SNF is 
the FROM date and the last day the patient is not in the SNF at midnight is the 
THROUGH date.  Report accommodation revenue code 18X (leave of absence) and the 
quantity of leave days.  Occurrence span code 74 should be reported for each interruption 
of more than 1 day along with the dates of each interruption.  Revenue code 018X should 
reflect the total number of days for all occurrence span code 74 entries.  In other words, 
revenue code 018X should be listed on one line, with all interrupted days included in the 
units column.  No charges should be added to this charge line. 
 
120.3 - Variable Per Diem (VPD) Adjustment  
(Rev.4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19) 
 
The Social Security Act requires that Medicare Part A-covered SNF stays be paid on a 
per-diem basis. PDPM SNF PPS per diem payments will be reduced according to a 
prescribed schedule, referred to as the VPD adjustment. Specifically, the PDPM provides 
for an adjustment factor that is applied to certain components and changes the per diem 
rate over the course of the stay. 
Thus, under PDPM, the per diem rate for a given day of the SNF PPS stay may be 
different from the prior day, depending on an adjustment factor that may be applied 
against the SNF PPS rate connected with the HIPPS code. Moreover, the VPD schedule 
applies only to the PT, OT, and NTA components of the per diem rate, with different 
schedules for the PT/OT components than for the NTA component. A similar adjustment 
exists under the Inpatient Psychiatric Facility (IPF) PPS. 
For the PT, OT, and NTA components, the case-mix adjusted per diem rate is multiplied 
against the variable per diem adjustment factor, following a schedule of adjustments for 
each day of the patients stay 
 
VPD Adjustment Schedules 
 
PT & OT Components 
 
 
Day in Stay  Adjustment Factor  Day in Stay  Adjustment Factor 
        1-20  1.00  63-69  0.86 
21-27  0.98  70-76  0.84 
28-34  0.96  77-83  0.82 
35-41  0.94  84-90  0.80 
42-48  0.92  91-97  0.78 
49-55  0.90  98-100  0.76 
56-62  0.88     
 
NTA Component 
 
Day in Stay  Adjustment Factor 
   
1-3  3.00 
4-100  1.00 
 
120.4 - AIDS Adjustments 
(Rev. 4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19) 
As under the previous RUG-IV model, patients with a B20 ICD-10 diagnosis code on 
the SNF claim, meaning the patient has AIDS/HIV, receive an adjustment factor for their 
PPS rate. Under PDPM, the adjustment factor is different from that used under RUG-IV. 
Rather than a 128 percent adjustment for the entire PPS per diem rate, the adjustment 
under PDPM is an increase of 18 percent in the nursing component of the per diem rate 
and a reclassification under the NTA component to a higher rate category. 
All other adjustment factors, such as adjustments for geographic variation in wage costs, 
remain the same under PDPM as under the previous RUG-IV model. 
 
120.5 - Transition Claims 
(Rev. 4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19) 
 
With regard to transition between RUG-IV and PDPM, a hard transition between the two 
systems has been implemented, such that days paid under RUG-IV would stop on 
September 30, 2019 and days would be paid under PDPM beginning October 1, 2019.  In order to receive a RUG-IV HIPPS code that can be billed for services furnished prior 
to October 1, 2019, providers must use an assessment with an ARD set for on or prior to 
September 30, 2019. 
If the patients stay begins on or after October 1, 2019, then the provider would begin 
with the 5-day assessment, as usual.  
For patients admitted prior to October 1, 2019, but whose stays continue past this date, in 
order to receive a PDPM HIPPS code that can be used to bill for services furnished on or 
after October 1, 2019, providers must complete an IPA with an ARD no later than 
October 7, 2019 (i.e., transitional IPA): 
October 1, 2019, will be considered Day 1 of the VPD schedule under PDPM, even if the 
patient began their stay prior to October 1, 2019. 
Any transitional IPAs with an ARD after October 7, 2019, will be considered late and 
relevant penalty for late assessments would apply (described below). 
 
120.6 - Default Billing 
(Rev. 4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19) 
 
As under RUG-IV, there may be instances in which providers may bill the default rate 
on a SNF claim (e.g., when an MDS assessment is considered late). 
  The default rate refers to the lowest possible per diem rate. 
  The default code under PDPM is ZZZZZ, as compared to the default code under 
RUG-IV of AAA00. 
  Billing the default code under PDPM represents the equivalent of billing the 
following PDPM groups: 
  PT Payment Group: TP 
  OT Payment Group: TP 
  SLP Payment Group: SA 
  Nursing Payment Group: PA1 
  NTA Payment Group: NF 
 
  Transmittals Issued for this Chapter 
Rev#  Issue Date  Subject  Impl Date  CR# 
R12283CP  10/05/2023  Internet Only Manual Updates to  01/08/2023  13271 
Pub. 100-02 and 100-04 to 
Implement Consolidated 
Appropriations Act 2023 Changes 
for Skilled Nursing Facility (SNF) 
R11109CP  11/04/2021  Skilled Nursing Facility (SNF)  01/03/2022  12344 
Claims Processing Updates 
R10904CP  08/10/2021  Skilled Nursing Facility (SNF)  01/03/2022  12344 
Claims Processing Updates  
Rescinded and replaced by 
Transmittal 11109 
R10880CP  06/08/2021  Internet Only Manual Updates to  11/08/2021  12009 
Pub. 100-01, 100-02, and 100-04 to 
Implement Consolidated 
Appropriations Act Changes and 
Correct Errors and Omissions (SNF) 
R10569CP  01/14/2021  Updates to Skilled Nursing Facility  04/05/2021  11992 
(SNF) Patient Driven Payment 
Model (PDPM) Claims   
R10448CP  11/06/2020  Updates to Skilled Nursing Facility  04/05/2021  11992 
(SNF) Patient Driven Payment 
Model (PDPM) Claims  Rescinded 
and replaced by Transmittal 10569  
R10236CP  07/31/2020  Update to the IOM Publication (Pub)  08/31/2020  11857 
100-04, Medicare Claims Processing 
Manual, Chapters 1, 6, 8, 17, 20, 22, 
24, and 31 Referencing the Active 
Universal Resource Locators (URLs) 
for the Washington Publishing 
Company (WPC) and the ASC X12 
Organizations, and Updates to the 
HIPAA Eligibility Transaction 
System (HETS) 
R10222CP  07/14/2020  Updates in the Fiscal Intermediary  10/05/2020  11797 
Shared System (FISS) Inpatient 
Provider Specific Files (PSF)  Rev#  Issue Date  Subject  Impl Date  CR# 
R10140CP  05/15/2020  Updates in the Fiscal Intermediary  10/05/2020  11797 
Shared System (FISS) Inpatient 
Provider Specific Files (PSF)- 
Rescinded and replaced by 
Transmittal 10222 
  01/09/2020  Updates to CR 11152  04/06/2020  11513 
Implementation of the Skilled 
Nursing Facility (SNF) Patient 
Driven Payment Model (PDPM) 
 
R4409CP  10/04/2019  Manual Updates for CR11152  11/05/2019  11454 
Implementation of the Skilled 
Nursing Facility (SNF) Patient 
Driven Payment Model (PDPM) 
R4247CP  03/01/2019  Update to Publication 100-04  04/01/2019  11155 
Chapters 2, 6, and 18 to Provide 
Language-Only Changes for the New 
Medicare Card Project 
R4157CP  11/02/2018  Hospital and Critical Access Hospital  04/01/2019  10962 
(CAH) Swing-Bed Manual Revisions 
 
and Shared Systems Changes 
R4163CP  11/02/2018  Internet Only Manual Updates to  12/04/2018  11004 
Pub. 100-01, 100-02 and 100-04 to 
Correct Errors and Omissions (SNF) 
(2018 Q4) 
R4001CP  03/16/2018  Internet Only Manual Updates to  06/19/2018  4001 
Pub. 100-01, 100-02 and 100-04 to 
Correct Errors and Omissions (SNF) 
(2018) 
R3612CP  09/16/2016  Internet Only Manual Updates to  10/18/2016  9748 
Pub. 100-01, 100-02 and 100-04 to 
Correct Errors and Omissions (SNF) 
R3481CP  03/18/2016  Updates to Pub. 100-04, Chapters 3,  06/20/2016  9562 
6, 7 and 15 to Correct Remittance 
Advice Messages  Rev#  Issue Date  Subject  Impl Date  CR# 
R3379CP  10/16/2015  Internet Only Manual Updates to  11/16/2015  9336 
Pub. 100-01, 100-02 and 100-04 to 
Correct Errors and Omissions (2015) 
R3230CP  04/03/2015  Updates to the Medicare Internet- 06/15/2015  8997 
Only Manual Chapters for Skilled 
Nursing Facility (SNF) Providers 
R3220CP  03/16/2015  Update to Pub. 100-04, Chapters 5  09/16/2014  8524 
and 6 to Provide Language-Only 
Changes for Updating ICD-10, ASC 
X12, and Medicare Administrative 
Contractor (MAC) Implementation 
R3216CP  03/13/2015  Updates to the Medicare Internet- 06/15/2015  8997 
Only Manual Chapters for Skilled 
Nursing Facility (SNF) Providers  
Rescinded and replaced by 
Transmittal 3230 
R3028CP  08/15/2014  Update to Pub. 100-04, Chapters 5  09/16/2014  8524 
and 6 to Provide Language-Only 
Changes for Updating ICD-10, ASC 
X12, and Medicare Administrative 
Contractor (MAC) Implementation  
Rescinded and replaced by 
Transmittal 3220 
R2921CP  04/04/2014  Internet Only Manual Updates to  05/05/2014  8669 
Pub. 100-01, 100-02 and 100-04 to 
Correct Errors and Omissions 
R2899CP  03/07/2014  Pub 100-04, Language Only Update  10/01/2014  8524 
for Chapters Five and Six for 
Conversion to ICD-10 
R2815CP  11/15/2013  Updates to the Medicare Claims  03/18/2014  8490 
Processing Internet-Only Manual 
(IOM) 
R2802CP  10/25/2013  2014 Annual Update of Healthcare  01/06/2014  8474 
Common Procedure Coding System 
(HCPCS) Codes for Skilled Nursing 
Facility (SNF) Consolidated Billing 
(CB) Update  Rev#  Issue Date  Subject  Impl Date  CR# 
R2573CP  10/26/2012  Manual Updates to Clarify SNF  04/01/2013  8044 
Claims Processing 
R2399CP  01/26/2012  Clarification for Skilled Nursing  07/02/2012  7717 
Facility (SNF) and Swing Bed (SB) 
Part A Billing - Updating System 
Requirements for Assessment Date 
Reporting and Removal of the 
Occurrence Code 16 Reporting 
Requirement 
R2377CP  12/30/2011  Manual Revision to Chapter 6,  01/31/2012  7658 
Section 20.1.1 Physicians Services 
and Other Professional Services 
Excluded From Part A PPS Payment 
and the Consolidated Billing 
Requirement 
R2245CP  06/16/2011  Manual Clarifications for Skilled  08/01/2011  7339 
Nursing Facility (SNF) Part A 
Billing 
R2239CP  06/14/2011  Manual Clarifications for Skilled  08/01/2011  7339 
Nursing Facility (SNF) Part A 
Billing  Rescinded and replaced by 
Transmittal 2245 
R2183CP  03/25/2011  Manual Clarifications for Skilled  06/28/2011  7339 
Nursing Facility (SNF) Part A 
Billing  Rescinded and replaced by 
Transmittal 2239 
R2028CP  08/13/2010  5010 Implementation--Processing  01/03/2011  7004 
Additional International 
Classification of Diseases, 9th 
Revision-Clinical Modification 
(ICD-9-CM) Diagnosis and 
Procedure Codes in Pricer, Grouper, 
and the Medicare Code Editor 
(MCE) 
R2016CP  07/30/2010  5010 Implementation--Processing  01/03/2011  7004 
Additional International 
Classification of Diseases, 9th 
Revision-Clinical Modification  Rev#  Issue Date  Subject  Impl Date  CR# 
(ICD-9-CM) Diagnosis and 
Procedure Codes in Pricer, Grouper, 
and the Medicare Code Editor 
(MCE) - Rescinded and replaced by 
Transmittal 2028 
R2011CP  07/30/2010  Revised Instructions for Reporting  01/03/2011  7019 
Assessment Dates under the Inpatient 
Rehabilitation Facility (IRF), Skilled 
Nursing Facility (SNF), and Swing 
Bed (SB) Prospective Payment 
Systems (PPS) 
R1958CP  04/28/2010  Skilled Nursing Facility (SNF)  10/04/2010  6916 
Health Insurance Prospective 
Payment System (HIPPS) Coding 
Updates Effective October 1, 2010 
R1911CP  02/05/2010  Implementation of a New Skilled  07/06/2010  6702 
Nursing Facility (SNF) Consolidated 
Billing (CB) Edit for Facility 
Services Billed by Ambulatory 
Surgical Centers (ASCs) 
R1814CP  09/04/2009  2010 Annual Update of Healthcare  01/04/2010  6619 
Common Procedure Code System 
(HCPCS) Codes for Skilled Nursing 
Facility (SNF) Consolidated Billing 
(CB) Update 
R1757CP  06/19/2009  Claims Processing for Skilled  07/20/2009  6521 
Nursing Facility Consolidated Billing 
R1749CP  06/05/2009  Revised Billing Instructions for  10/05/2009  6523 
Occurrence Span Code 74 on Skilled 
Nursing Facility (SNF) No Payment 
Claims 
R1733CP  05/08/2009  Manual Clarification for Skilled  04/27/2009  6407 
Nursing Facility (SNF) and Therapy 
Billing 
R1706CP  03/27/2009  Manual Clarification for Skilled  04/27/2009  6407 
Nursing Facility (SNF) and Therapy  Rev#  Issue Date  Subject  Impl Date  CR# 
Billing  Rescinded and replaced by 
Transmittal 1733 
R1618CP  10/24/2008  Revision to the Reporting  04/06/2009  6233 
Requirements of Qualifying Hospital 
Stays on Inpatient Skilled Nursing 
Facility (SNF) and Swing Bed (SB) 
Claims 
R1565CP  07/25/2008  Clarification on the Correct  01/05/2009  6002 
Condition Code to Report on 
Provider Adjustment Requests to 
Indicate a Health Insurance 
Prospective Payment System 
(HIPPS) Code Change 
R1555CP  07/18/2008  Revision of the Requirements for  01/05/2009  6116 
Denial of Payment for New 
Admissions (DPNA) for Skilled 
Nursing Facility (SNF) Billing 
R1554CP  07/18/2008  Revision to Skilled Nursing Facility  01/05/2009  6128 
(SNF) Common Working File 
(CWF) Editing 
R1553CP  07/18/2008  Clarification on the Correct  01/05/2009  6002 
Condition Code to Report on 
Provider Adjustment Requests to 
Indicate a Health Insurance 
Prospective Payment System 
(HIPPS) Code Change - Rescinded 
and replaced by Transmittal 1565 
R1472CP  03/06/2008  Update of Institutional Claims  04/07/2008  5893 
References 
R1450CP  02/15/2008  Update to the Common Working File  07/07/2008  5872 
(CWF) to Allow the Posting of 
Skilled Nursing Facility (SNF) and 
Swing Bed (SB) Claims to the 
Beneficiarys Spell of Illness When 
Qualifying Stay Criteria are Not Met  Rev#  Issue Date  Subject  Impl Date  CR# 
R1421CP  01/25/2008  Update of Institutional Claims  04/07/2008  5893 
References - Rescinded and 
Replaced by Transmittal 1472 
R1394CP  12/14/2007  Manual Updates to Chapter 6,  03/17/2008  5840 
Skilled Nursing Facility (SNF) 
Inpatient Part A Billing for No 
Payment and Medicare Advantage 
(MA) Claims 
R1365CP  11/02/2007  Additional Common Working File  04/07/2008  5757 
(CWF) Editing for Skilled Nursing 
Facility (SNF) Consolidated Billing 
(CB)  Part II 
R1355CP  10/19/2007  National Uniform Billing Committee  01/22/2008  5734 
(NUBC) Update on Revenue Codes 
and Corrected Skilled Nursing 
Facility (SNF) Spell of Illness Chart 
R1290CP  07/13/2007  Clarification of Skilled Nursing  01/07/2008  5653 
Facility (SNF) Billing Requirements 
for Beneficiaries Enrolled in 
Medicare Advantage (MA) Plans 
R1289CP  07/13/2007  Additional Common Working File  01/02/2008  5624 
(CWF) Editing for Skilled Nursing 
Facility (SNF) Consolidated Billing 
(CB) 
R1252CP  05/25/2007  Clarification of Skilled Nursing  08/27/2007  5583 
Facility (SNF) No Pay Billing 
R1151CP  01/11/2007  Skilled Nursing Facility (SNF)  04/02/2007  5389 
Consolidated Billing (CB) Common 
Working File (CWF) Edit Bypass 
Instructions for Hospital Emergency 
Room (ER) Services Spanning 
Multiple Service Dates 
R1109CP  11/09/2006  Skilled Nursing Facility (SNF)  04/02/2007  5389 
Consolidated Billing (CB) Common 
Working File (CWF) Edit Bypass 
Instructions for Hospital Emergency  Rev#  Issue Date  Subject  Impl Date  CR# 
Room (ER) Services Spanning 
Multiple Service Dates 
R1068CP  09/27/2006  2007 Annual Update of HCPCS  01/02/2007  5283 
Codes for Skilled Nursing Facility 
(SNF) Consolidated Billing (CB) for 
the Common Working File (CWF), 
Medicare Carriers and Fiscal 
Intermediaries (FIs) 
R1009CP  07/28/2006  Correction to Skilled Nursing  01/02/2007  5220 
Facility (SNF) Consolidated Billing 
(CB) Enforcement if SNF Inpatient 
Claims are Partially Non-Covered 
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 
R930CP  04/28/2006  Benefits Exhaust and No-Payment  10/02/2006  4292 
Billing Instructions for Medicare 
Fiscal Intermediaries (FIs) and 
Skilled Nursing Facilities (SNFs) 
R926CP  04/28/2006  Common Working File (CWF) File  10/02/2006  4390 
Change for Skilled Nursing Facility 
(SNF) Consolidated Billing (CB) 
R846CP  02/10/2006  New Skilled Nursing Facility  03/13/2006  4297 
Consolidated Billing Web Site 
Address 
R767CP  12/02/2005  SNF PPS Revisions to IOM 100-04- N/A  4080 
Manualization 
R740CP  11/01/2005  Change to the Common Working  04/03/2006  3910 
File (CWF) Skilled Nursing Facility 
(SNF) Consolidated Billing (CB) 
Edits for Evaluation and 
Management (E&M) Services Billed 
to Fiscal Intermediaries (FIs) by 
Hospitals  Rev#  Issue Date  Subject  Impl Date  CR# 
R696CP  10/07/2005  2006 Annual Update of HCPCS  01/03/2006  4086 
Codes for Skilled Nursing Facility 
(SNF) Consolidated Billing (CB) for 
the Common Working File (CWF), 
Medicare Carriers and Fiscal 
Intermediaries (FIs) 
R685CP  09/23/2005  Discontinuation of the Skilled  12/27/2005  4044 
Nursing 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 
R630CP  07/29/2005  Medicare Part A Skilled Nursing  01/03/2006  3962 
Facility (SNF) Prospective Payment 
System (PPS) Pricer Update and 
Health Insurance Prospective 
Payment System (HIPPS) Coding 
Update Effective January 1, 2006 
R540CP  04/29/2005  Addition to Chapter 6 of the Claims  08/01/2005  3774 
Processing Manual - Skilled Nursing 
Facility (SNF) Inpatient Part A 
Billing: SNF Prospective Payment 
System (PPS) Pricer Software 
R459CP  02/04/2005  Full Replacement of Change Request  04/05/2005  3676 
(CR) 3427, Transmittal 342, Issued 
on October 29, 2004- Change to the 
Common Working File (CWF) 
Skilled Nursing Facility (SNF) 
Consolidated Billing (CB) Edits for 
Ambulance Transports to or from a 
Diagnostic or Therapeutic Site 
R437CP  01/21/2005  Revisions and Corrections to the  02/22/2005  3664 
Medicare Claims Processing Manual, 
Chapter 6, Section 30 and Various 
Sections in Chapter 15 
R429CP  01/14/2005  Change to the Common Working  07/05/2005  3561 
File (CWF) Skilled Nursing Facility 
(SNF) Consolidated Billing (CB)  Rev#  Issue Date  Subject  Impl Date  CR# 
Edits for Critical Access Hospitals 
(CAHs) that have Elected Method II 
Payment Option and Bill Physician 
Services to their Fiscal 
Intermediaries (FIs) 
R413CP  12/23/2004  Medicare Part A Skilled Nursing  01/17/2005  3651 
Facility (SNF) Prospective Payment 
System (PPS) Pricer Update FY 2005 
for 9 Metropolitan Statistical Areas 
(MSAs) with New Wage Index 
Values Effective January 1, 2005 
R412CP  12/23/2004  Skilled Nursing Facility (SNF)  01/24/2005  3592 
Consolidated Billing Service 
Furnished under an "Arrangement" 
with an Outside Entity 
R378CP  11/26/2004  Liability Days on Skilled Nursing  01/03/2005  3568 
Facility (SNF) and Swing Bed 
Facility Inpatient Bills 
R342CP  10/29/2004  Change to the Common Working  04/04/2005  3427 
File (CWF) Skilled Nursing Facility 
(SNF) Consolidated Billing (CB) 
Edits for Ambulance Transports to or 
from a Diagnostic or Therapeutic 
Site 
R268CP  07/30/2004  Medicare Part A Skilled Nursing  10/04/2004  3368 
Facility (SNF) Prospective Payment 
System (PPS) Pricer Update FY 2005 
R253CP  07/23/2004  Fiscal Intermediary Shared System  01/03/2005  3308 
(FISS) Changes to Allow for 
Provider Liability Days on Skilled 
Nursing Facility (SNF) and Swing 
Bed Facility Inpatient Bills 
R229CP  07/20/2004  Additional Clarification of Bill  08/19/2004  3323 
Types 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  Rev#  Issue Date  Subject  Impl Date  CR# 
R215CP  06/25/2004  Implementation of Skilled Nursing  07/06/2004  2944 
Facility Consolidated Billing CWF 
Edit for Therapy Codes Considered 
Separately Payable Physician 
Services 
R209CP  06/18/2004  Correction to CR 2944, Transmittal  07/06/2004  3333 
90, Issued on February 6, 2004 
R200CP  06/10/2004  Update to the Common Working File  10/04/2004  3277 
Edits for Skilled Nursing Facility 
(SNF) Consolidated Billing (CB) to 
Expand the Bypass for Pharmacy 
Services. 
R183CP  05/21/2004  Skilled Nursing Facility (SNF)  07/01/2004  3248 
Consolidated Billing: Services 
Furnished Under an "Arrangement" 
With an Outside Entity 
R163CP  04/30/2004  Change to the Common Working  10/04/2004  3196 
File (CWF) Skilled Nursing Facility 
(SNF) Consolidated Billing (CB) 
Edits for Ambulance Transports to or 
from a Diagnostic or Therapeutic 
Site Other than a Physician's Office 
or Hospital 
R133CP  04/02/2004  Billing NonCovered Charges to  04/16/2004  3115 
Fiscal Intermediaries - Summary and 
New Instructions - Clarification 
R094CP  02/06/2004  Additional Information in Medicare  07/06/2004  3098 
Summary Notices (MSNs) to 
Beneficiaries about Skilled Nursing 
Facility (SNF) Benefits 
R092CP  02/06/2004  Updates to the January 2004 Annual  04/05/2004  3070 
Update of HCPCS Codes Used for 
Skilled Nursing Facility 
Consolidated Billing Enforcement 
R090CP  02/06/2004  Implementation of Skilled Nursing  07/06/2004  2944 
Facility Consolidated Billing CWF 
Edit for Therapy Codes Considered  Rev#  Issue Date  Subject  Impl Date  CR# 
Separately Payable Physician 
Services 
R076CP  02/06/2004  SNF Inpatient Part A Billing  N/A  3133 
R001CP  10/01/2003  Initial Publication of Manual  NA  NA 
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