(Medicare Claims Processing Manual)

Sections 1861(s)(14)  and 1861(nn) of the Act, (as enacted by 6115 of the Omnibus Budget Reconciliation Act of 1989) provides for coverage of screening pap smears for services provided on or after July 1, 1990.  Screening pap smears are laboratory tests consisting of a routine exfoliative  cytology test (Papanicolaou test) provided for the purpose of early detection of cervical cancer.  It includes a collection of the sample of cells and a physician's interpretation of the test.   Payment is made under the clinical diagnostic laboratory fee schedule.   80.4 - Screening Pelvic Examinations  (Rev. 1, 10- 01-03)  Section 4102 of the BBA of 1997 (P.L.  105 -33) amended 1861(nn) of the Act (42 USC 1395X(nn)) to include coverage of screening pelvic examinations for all female beneficiaries for services provided January 1, 1998, and later.  Effective July 1, 2001, the Consolidated Appropriations Act of 2001 (P.L.  106- 554) modifies 1861(nn) to provide Medicare coverage for biennial screening pelvic examinations.   Payment is made under the Medicare Physician's Fee Schedule (MPFS).   80.5 - Prostate Cancer Screening  (Rev. 1, 10- 01-03)  Sections 1861(s)(2)(P) and 1861(oo)  of the Act (as added by 4103 of the Balanced Budget Act of 1 997), provide for coverage of certain prostate cancer screening tests subject to certain coverage, frequency, and payment limitations.  Effective for services furnished on or after January 1, 2000, Medicare covers prostate cancer screening tests/procedures  for the early detection of prostate cancer.  Coverage of prostate cancer screening tests includes the following procedures furnished to an individual for the early detection of prostate cancer:    Screening digital rectal examination; and   Screening prostate specific antigen (PSA) blood test   Each test may be paid at a frequency of once every 12 months for men who have attained age 50 (i.e., starting at least one day after they have attained age 50), if at least 11 months have passed following the month in which the last Medicare- covered screening digital rectal examination was performed (for digital rectal exams) or PSA test was performed (for PSA tests).   Payment is made under the clinical diagnostic laboratory fee schedule.   80.6 - Colorectal Cancer Screening  (Rev. 1, 10- 01-03)  See the Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Health Services," 80.5, for coverage of colorectal rectal screening services.   Effective for services furnished on or after January 1, 1998, payme nt may be made for colorectal cancer screening for the early detection of cancer.  For screening colonoscopy services (one of the types of services included in this benefit) prior to July 2001, coverage was limited to high -risk individuals.  For services J uly 1, 2001, and later, screening colonoscopies are covered for individuals not at high risk.  Screening colonoscopies are not payable to the SNF.  Screening colonoscopies are only covered when rendered in a hospital or CAH.  For all other colorectal screening services payment is made under the MPFS or the clinical diagnostic laboratory fee schedule based on the service rendered.   80.7 - Glaucoma Screening  (Rev. 1, 10- 01-03)  The Benefits Improvement and Protection Act of 2000, 102, provides annual coverag e for glaucoma screening for Medicare beneficiaries with diabetes mellitus, or a family history of glaucoma, or African -Americans age 50 and over.  Conditions of coverage for glaucoma screening are located in the Medicare Benefit Policy Manual, Chapter 15,  "Covered Medical and Other Health Services."   Payment is made under the Medicare Physician's Fee Schedule (MPFS).   90 - Billing for Laboratory Tests Under Part B - General  (Rev. 1, 10- 01-03)  Section 1833(h)(5) of the Act (as enacted by The Deficit Reduction Act of 1984, Public Law 98 -369) requires the establishment of a fee schedule for clinical diagnostic laboratory tests  paid under Part B.   Section 1833g(5)(A)iii of Title XVIII provides that "in the case of a clinical diagnostic laboratory test provided under an arrangement (as defined in 1861(w)(1) ) made by a hospital, critical access hospital or skilled nursing facility, payment shall be made to the hospital or skilled nursing facility."  SNFs must  make arrangements under Par t A and may make arrangements under Part B under which the SNF bills the intermediary and receives payment.  Under this process, the SNF pays the lab for services whatever amount the SNF and the lab agree on, and the beneficiary may not be charged by the l ab.  Where the SNF and a lab have entered into such an arrangement, the arrangement may include Part A only or may include Part A and Part B.  Such an arrangement is voluntary on the part of both the lab and the SNF for Part B services.   In the absence of such an arrangement under Part B, the lab may bill the program for lab services furnished to residents for whom Part A cannot be paid, and for SNF outpatients, and the SNF may not bill the program for these services.  Hospital labs and labs in other SNFs w ould bill the intermediary.  Independent labs would bill the carrier.   Laboratory tests performed for the SNF's Medicare inpatients covered under Part A are included in the PPS SNF payment.  If the FI receives fee amounts for HCPCS included on both the cli nical diagnostic laboratory fee schedule and the SNF extract of the MPFS, the SNF receives the amount on the laboratory fee schedule.   Payment is made for specimen collection fees and travel allowance as discussed in Medicare Claims Processing Manual, Chap ter 16, "Laboratory Services from Independent Labs, Physicians, and Providers."   Bill type 22X for lab services to Part B residents and 23X for nonresidents should be used.  Neither deductible nor coinsurance applies to lab fee schedule payments.   See the Medicare Claims Processing Manual, Chapter 16, "Laboratory Services from Independent Labs, Physicians, and Providers," for additional coverage, billing, and payment requirements.  90.1 - Glucose Monitoring  (Rev. 1, 10- 01-03)  Medicare Part B may pay for a glucose monitoring device and related disposable supplies under its durable medical equipment benefit if the equipment is used in the home or in an institution that is used as a home.  A hospital or SNF is not considered a home under this benefit ( 1861(h)  of the Act, 42 CFR 410.38).  Routine glucose monitoring of diabet ics is never covered in a SNF, whether the beneficiary is in a covered Part A stay or not.  Glucose monitoring may only be covered when it meets all the conditions of a covered laboratory service, including use by the physician in modifying the patient's t reatment.   100 - Epoetin (EPO)  (Rev. 1, 10- 01-03) SNF -543  EPO is a biologically engineered protein which stimulates the bone marrow to make new red blood cells.  Patients with anemia associated with chronic renal failure include all ESRD patients regardless of whether they are on dialysis.   EPO is covered for the treatment of anemia for patients with chronic renal failure who are receiving dialysis when it is administered in a renal dialysis facility (RDF).   EPO is not included in SNF PPS and may b e billed separately when given in conjunction with dialysis by the Renal Dialysis Facility.  It must be billed by the RDF.   EPO is not a SNF outpatient benefit.   110 - Carrier Claims Processing for Consolidated Billing for Physician and Non -Physician Pract itioner Services Rendered to Beneficiaries in a Non-Covered SNF Stay (Rev. 846, Issued:  02- 10-06; Effective:  12- 15-05; Implementation:  03 -13-06)  For Medicare beneficiaries in a non -covered stay, only therapy services are subject to consolidated billing . All other covered SNF services must be separately billed to the carrier for payment consideration. Refer to section 110 in Chapter 6, SNF Inpatient Part A Billing for additional information on carrier claims processing. A list of therapy codes that are s ubject to consolidated billing for beneficiaries in a non- covered SNF stay can be found on the CMS Web site at http://www.cms.hhs.gov/SNFConsolidatedBilling/ .  Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R10880CP  08/06/2021 Internet Only Manual Updates to Pub. 100-01, 100- 02, and 100- 04 to Implement Consolidated Appropriations Act Changes and Correct Errors and Omissions (SNF)  11/08/2021 12009 R3481CP 03/18/2016 Updates to Pub. 100- 04, Chapters 3, 6, 7 and 15 to Correct Remittance Advice Messages  06/20/2016 9562 R3053CP 08/28/2014 Update to Pub. 100- 04, Chapters 7 and 8 to Provide Language -Only Changes for Updating ICD -10 and ASC X12 09/30/2014 8579 R2905CP  03/14/2014 Update to Pub. 100- 04, Chapters 7 and 8 to Provide Language -Only Changes for Updating ICD -10 and ASC X12  Rescinded  and replaced by Transmittal 3053 10/01/2014 8579 R1472CP  03/06/2008 Update of Institutional Claims References  04/07/2008 5893 R1421CP 01/25/2008 Update of Institutional Claims References -  Rescinded and Replaced by Transmittal 1472  04/07/2008 5893 R980CP 06/14/2006 Changes Conforming to CR 3648 Instructions for Therapy Services -  Replaces Rev. 941  10/02/2006 4014 R941CP 05/05/2006 Changes Conforming to CR 3648 Instructions for Therapy Services  10/02/2006 4014 R846CP 02/10/2006 New Skilled Nursing Facility Consolidated Billing Web site Address  03/13/2006 4297 R685CP 09/23/2005 Discontinuation of the Skilled Nursing Facility (SN F) HCPCS Help File and Notification to Fiscal Intermediaries (FIs) and Providers of the Redesigned SNF Consolidated Billing (CB) 12/27/2005 4044 Annual Update File Posted on CMS Web Site  R351CP  10/29/2004 Editing of Hospitals and Skilled Nursing Facilities Part B Inpatient Services (Full Replacement of Change Request 3366)  01/03/2005 3531 R301CP 09/17/2004 Editing Of Hospital And Skilled Nursing Facility Part B Inpatient Services  01/03/2005 3366 R251CP 07/23/2004 Editing Of  Hospital And Skilled Nursing Facility Part B Inpatient Services  01/03/2005 3366 R229CP 07/20/2004 Additional Clarification of Bill Types 22x and 23x Submitted by Skilled Nursing Fac ilities (SNFs) With Instructions for Involuntarily Moving a Beneficiary Out of the SNF and Ending a Benefit Period  08/19/2004 3323 R076CP 02/06/2004 SNF Inpatient Part A Billing  N/A 3133 R020CP  10/31/2003 Add a paragraph regarding the SNF NO PAY FILE  11/05/2003 2968 R001CP 10/01/2003 Initial Publication of Manual  NA NA Back to top of Chapter