(Medicare Benefit Policy Manual)

 Diagnostic x- ray tests, diagnostic laboratory tests, and other diagnostic tests;    X-ray, radium, and radioactive isotope therapy, including materials and services of technicians;    Surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations;    Prosthetic devices (other than dental) which replace all or part of an internal body organ (including contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body organ, including replacement or repairs of  such devices;    Leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes including adjustments, repairs, and replacements required because of breakage, wear, loss, or a change in the patients physical condition;    Outpatient physical therapy, outpatient speech language pathology services, and outpatient occupational therapy (see Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 10, Covered Medical and Other Health Services, 220.1.4);    Screening mammography services;    Screening pap smears and pelvic exams;    Influenza, pneumococcal pneumonia, and hepatitis B vaccines;    Some colorectal screening;    Prostate screening;    Ambulance services;    Hemophilia clotting factors.    Epoetin Alfa (EPO) for ESRD beneficiaries when given in conjunction with dialysis.   See Pub. 100- 04, Medicare Claims Processing Manual chapter 6, for information on billing for these services.  See 70.1 of this chapter for the conditions under which diagnostic services and radiological therapy furnished by SNFs are covered.  For coverage of total parenteral nutrition (TPN) and enteral nutrition (EN) as a prosthetic device, see Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B, and the Medicare National Coverage Determinations Manual, chapter 1, Part 3, 180.2.  Rental or purchase of durable medical equipment from SNFs for use in the patients home (other than a hospital or SNF, as discussed in Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15, 110.1.D) is covered under Part B in accordance with the provisi ons of Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B, 80 (also see Pub. 100- 04, Medicare Claims Processing Manual, chapter 7, 60, for the related SNF billing instructions).  DME rendered to Part A inpati ents of a SNF is covered as part of the prospective payment system and is not separately payable.  For coverage of provider ambulance services, see Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B".  Drugs, biologicals, and blood are not covered under Part B when furnished by a SNF.   70.1 - Diagnostic Services and Radiological Therapy  (Rev. 1, 10- 01-03)  A3-3137.1, SNF -260.1   Diagnostic x- ray and radiological therapy may be provided directly by a SNF if, as part of its compliance with the conditions of participation, the SNF has a radiological department, which meets the same standards required of a hospital furnishing such services under the program, or if the SNF meets the portable x- ray supplier standards.  Portable x -ray services provided by a SNF under arrangements are covered only if furnished by an approved supplier.  When a SNF furnishes laboratory services directly, it must have a Clinical Laboratory Improvement Act (CLIA) number or a CLIA certificate of waiver.  SNFs may bill for laboratory services rendered under arrangement for tests NOT on the CLIA waived list.   70.2 - Ambulance Service  (Rev. 1, 10- 01-03)  A3-3138, SNF -260.C   For requirements relating to provider ambulance service, see the Medicare Benefit Policy Manual, Chapter 10, Ambulance Services.   70.3 - Inpatient Physical Therapy, Occupational Therapy, and Speech -Language Pathology Services  (Rev. 37, Issued:  08 -12-05; Effective/Implementation:  09 -12-05)  Under Part A, physical therapy, occupational therapy, and speech pathology services are included in the SNF PPS rate for cost reporting periods beginning on or after July 1, 1998.  For inpatient Part B residents and outpatient services, payment for such se rvices is under a fee schedule.  The SNF must bill for physical therapy, occupational therapy, or speech -language pathology services for Part A residents beginning with its first cost reporting period that starts on or after July 1, 1998, and for Part B for services furnished on or after July 1, 1998.  The SNF (rather than an outside provider/supplier such as an approved clinic or rehabilitation agency, or a participating hospital) bills Medicare.  Payment is made directly to the SNF.  The patient is respon sible only for applicable Part A coinsurance or the Part B deductible and coinsurance amounts.  See also the Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services.      70.4 - Services Furnished Under Arrangements With Providers  (Rev. 261, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19)  The SNF may arrange with others to furnish covered services such as physical therapy, occupational therapy, or speech- language pathology services. The SNF (rather than an outside provider/supplier, another SNF or a HHA) bills Medicare, and payment is made directly to the SNF. When such arrangements are made, SNF receipt of payment for the arranged services (as with services provided directly) relieves the beneficiary or any other person of further liability to pay for them. See Pub. 100- 01, Medicare General  Information, Eligibility, and Entitlement Manual, chapter 5, section 10.3, for a general discussion of services furnished under arrangements.   The specific details of the ensuing payment arrangement between the SNF and the outside supplier (such as the actual payment amount and timeframe) represent a private, marketplace transaction that is negotiated between the parties themselves and falls outside the purview of CMS. This means, for example, that payments by the SNF to an outside supplier for bundled services furnished to the SNFs Part A resident under an arrangement made with the outside supplier are not governed by the specific Medicare fee schedule amounts or claims processing timeframes that would apply to services billed to Medicare separately under Part B; however, in order for the arrangement itself to be valid, the SNF must, in fact, make payment to its supplier for services rendered. See Pub. 100-04, Medicare Claims Processing Manual, chapter 6, sections 10.4ff. for additional information on arrangements between SNFs and their suppliers.   The arrangement must also comply with the fraud and abuse laws (see Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, chapter 1, section 20.3, and Pub. 100- 04, Medicare Claims Processing Manual, chapter 6, section 80.5). Quest ions about the interpretation and enforcement of the statutory anti -kickback provisions in section 1128B(b) of the Social Security Act should be directed to the attention of the Industry Guidance Branch in HHSs Office of the Inspector General (OIG); see the regulations at 42 CFR Part 1008 and the OIG website at https://oig.hhs.gov/compliance/advisory-opinions/index.asp.      Transmittals Issued for this Chapter   Rev #  Issue Date  Subject  Impl Date  CR#  R12283BP  10/05/2023  Internet Only Manual Updates to Pub. 100-02 and 100-04 to Implement Consolidated Appropriations Act 2023 Changes for Skilled Nursing Facility (SNF)  01/08/2024  13271  R10880BP  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  R261BP  10/04/2019  Manual Updates for CR11152 Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) 11/05/2019  11454  R249BP  11/02/2018  Internet Only Manual Updates to Pub. 100- 01, 100-02 and 100-04 to Correct Errors and Omissions (SNF) (2018 Q4) 12/04/2018  11004  R242BP  03/16/2018  Internet Only Manual Updates to Pub. 100- 01, 100-02 and 100-04 to Correct Errors and Omissions (SNF) (2018) 06/19/2018  10512  R228BP  10/13/2016  Internet Only Manual Updates to Pub. 100- 01, 100-02 and 100-04 to Correct Errors and Omissions (SNF)  10/18/2016  9748 R227BP  09/16/2016  Internet Only Manual Updates to Pub. 100- 01, 100-02 and 100-04 to Correct Errors and Omissions (SNF)   Rescinded and replaced by Transmittal 228  10/18/2016  9748 R211BP  10/16/2015  Internet Only Manual Updates to Pub. 100- 01, 100-02 and 100-04 to Correct Errors and Omissions (2015) 11/16/2015  9336 R204BP  03/13/2015  Updates to the Medicare Internet -Only Manual Chapters for Skilled Nursing Facility (SNF) Providers 06/15/2015  8997 R183BP  04/04/2014  Internet Only Manual Updates to Pub. 100- 01, 100-02 and 100-04 to Correct Errors and Omissions  05/05/2014  8669 R182BP  03/21/1014  Implementing the Part B Inpatient Payment Policies from CMS -1599-F 04/21/2014  8666 R179BP  01/14/2014  Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius 01/07/2014  8458 R176BP  12/13/2013  Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius  Rescinded and replaced by Transmittal 179 01/07/2014  8458 R161BP  10/26/2012  Manual Updates to Clarify SNF Claims Processing  04/01/2013  8044 R155BP  04/20/2012  Allowing Physician Assistants to Perform Skilled Nursing Facility (SNF) Level of Care Certifications and Recertifications  02/13/2012  7701 R153BP  1/13/2012 Allowing Physician Assistants to Perform Skilled Nursing Facility (SNF) Level of Care Certifications and Recertifications  Rescinded and replaced by Transmittal 155 02/13/2012  7701 R89BP  05/16/2008  Medical and Other Health Services Furnished to SNF Patients  06/16/2008  5991 R73BP  06/29/2007  Coverage Requirements for Therapy Services Provided in a Skilled Nursing Facility 10/01/2007  5532 R58BP  11/09/2006  Swing Bed Hospital Updates 12/11/2006  5114 R57BP  11/08/2006  Clarification/Update to Chapter 8, Pub. 100-02 12/14/2006  4220 R54BP  09/15/2006  Clarification/Update to Chapter 8, Pub. 100-02 12/14/2006  4220 R40BP  11/18/2005  Skilled Nursing Facility Prospective Payment System  02/16/2006  4079 R37BP  08/12/2005  Conforming Changes for Change Request 3648 to Pub. 100-02 09/12/2005  3912 R1BP  10/01/2003  Introduction to the Benefit Policy Manual N/A N/A Back to top of Chapter