(Medicare Claims Processing Manual)

Prosthetic and orthotic devices are:    Prosthetic devices (other than dental) that replace all or part of an internal body organ (including connective tissue) or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ, including replacement or repair of such devices (see the Medicare Benefit Policy Manual, Chapter 15, "Covered Medi cal and Other Health Service," 120); and    Leg, arm, and neck braces, trusses, and artificial legs, arms, and eyes, including adjustments, repairs, and replacement required because of breakage, wear, loss, or a change in the patient's physical condition (s ee the Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Health Service," 130).   SNFs bill supplies to its A/B MAC (A) for outpatients.   60.1 - Billing (Rev. 3053, Issued: 08- 28-14, Effective: ICD -10: Upon Implementation of ICD -10 ASC- X12: 01- 01-12, Implementation ICD -10: Upon Implementation of ICD -10; ASC X12: 09 -30-14)  The SNF must bill the A/B MAC (A) for prosthetic/orthotic devices, supplies and surgical dressings using the ASC X12 837 institutional claim format or if permissib le Form CMS -1450.  Requirements for billing can be found in the Medicare Claims Processing Manual, Chapter 25, "Completing and Processing the CMS 1450 Data Set."   The SNF must bill prosthetic and orthotic devices under revenue code 274, along with the appropriate HCPCS code.  When billing for maintenance and servicing of these items, revenue code 274 along with the appropriate HCPCS code must be used.  The SNF should report "Units of Service" on Form CMS -1450 the number of items billed to the SNF's A/B MAC (A) for orthotics and prosthetics.  Supplies may be billed for SNF outpatients under revenue code 270.  Payment is made based on a fee schedule.   The SNF should bill the A/B MAC (A) for surgical dressings under revenue code 623.  HCPCS codes for reporting surgical dressing are normally found in the Level II HCPCS codes in the A6000 series.  The A/B MAC (A) makes payment based on the surgical dressing fee schedule.   SNFs use 22X type of bill for orthotic and prosthetic devices and surgical dressings when billing for its Part B inpatients.  Orthotic and prosthetic devices, surgical dressings, and supplies for outpatients are billed with 23X type of bill.  (See the Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Health Service," 100 for coverage data.)   60.2 - Determining Payment and Patient Liability  (Rev. 1, 10- 01-03) SNF -534.D, SNF -534.E   There may be prosthetic and orthotic devices, for which the SNF would bill that are not included in the fee schedule.  When fee schedule amounts are not available for a particular item, the intermediary will pay based on cost.   To determine the SNF's Part B payment, the SNF subtracts any unmet Part B deductible from the lower of the actual charge or the fee schedule amount for the item or service and multiply the remainder by 80 percent.  This is the final payment.  The patient's liability is the remaining 20 percent plus any deductible remaining to be met.   60.3 - Billing for Enteral and Parenteral Nutritional Therapy as a Prosthetic Device  (Rev. 1, 10- 01-03) (Rev. 3053, Issued: 08- 28-14, Effective: ICD -10: Upon Implementation of ICD -10 ASC- X12: 01- 01-12, Implementation ICD -10: Upon Implementation of ICD -10; ASC X12: 09 -30-14)  Parenteral nutritional (PEN) therapies including the necessary equipment, medical supplies and nutrients provided to an inpatient (where Part A payment cannot be made), or to individuals who are not inpatients are covered as a prosthesis under the Part B prosthetic device benefit as long as the requirements in the Coverage Manual are met, and the required documentation is submitted.   The SNF or the supplier must bill the DME MAC.  The SNF or supplier should refer to the most recent HCPCS directory or billing instructions distributed by the DME MAC for current HCPCS coding informa tion.  If the SNF bills the DME MAC., it must obtain a supplier number from the National Supplier Clearinghouse and must use the ASC X12 837 professional claim format, or if permissible Form CMS -1500.  Billing Instructions are in the Medicare Claims Proces sing Manual, Chapter 26, "Completing and Processing the Form CMS -1500 Data Set."    DME MAC jurisdictions are based on the residence of the beneficiary.  The DME MAC for each State is shown on the CMS Web site at  http://www.cms.hhs.gov/medicare/medicare -contracting/medicare -administrative -contractors/medicareadministrativecontractors.html  .  70 - Drugs  (Rev. 1, 10- 01-03) SNF -536, SNF 536.1   Drugs and biologicals furnished to outpatients for therapeutic purposes that are self -administered are not covered by Medicare unless those drugs and biologicals must be put directly into an item of durable medical equipment or a p rosthetic device.  Exceptions to this rule are:    Self administered drugs administered in an emergency situation;    Self-administered oral versions of covered injectable cancer drugs prescribed as an anti -cancer chemotherapeutic;    Self-administered anti -emetic drugs;    Oral anti -emetic drugs as full therapeutic replacements for intravenous dosage forms as part of a chemotherapeutic regimen provided that the drug(s) be administered or prescribed by a physician for use immediately before, at, or within 48 hours after the time of administration of the chemotherapeutic agent; and   Immunosuppressive drugs furnished to transplant patients.  See the Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Health Services," 50 for coverage of d rugs.   See the Medicare Claim Processing Manual, Chapter 17, "Drugs," 80 for billing and payment instructions.  Where covered under Part B, self administered drugs for SNF inpatients not entitled to Part A benefits should be billed using type of bill 22X, and for SNF outpatients, using type of bill 23X.   70.1 - Immunosuppressive Drugs Furnished to Transplant Patients  (Rev. 1, 10- 01-03)  Part B of Medicare cove rs FDA -approved immunosuppressive drugs.  Payment is made for those immunosuppressive drugs that have been specifically labeled as such and approved for marketing by the FDA, as well as those prescription drugs, such as prednisone, that are used in conjunc tion with immunosuppressive drugs as part of a therapeutic regimen reflected in FDA -approved labeling for immunosuppressive drugs.  Therefore, antibiotics, hypertensives, and other drugs that are not directly related to rejection are not covered.   Deductib le and coinsurance apply.  SNFs bill using TOB 22X for Part B residents and TOB 23x for outpatients.  See the Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Health Services," 50 for coverage of drugs.   See the Medicare Claim Processing Manual, Chapter 17, "Drugs," 80 for billing and payment instructions.  80 - Screening and Preventive Services  (Rev. 1, 10- 01-03)  Screening and preventive services are only covered as a Medicare Part B benefit.  When furnished to a beneficiary in a  SNF Part A covered stay, the SNF must bill its intermediary using 22X type of bill.  These services are billed on TOB 23x for SNF outpatients and beneficiaries outside the Medicare -certified SNF or DPU.   See 10.C for billing preventive services for covered SNF Part A inpatients.  A SNF may bill screening and preventive services for its Part B residents using 22X type of bill or the supplier may bill its carrier.  Screening and preventive services rendered to SNF outpatients may be billed with 23X type of bill or the supplier may bill its carrier.   HCPCS codes are required.  See the Medicare Claims Processing Manual, Chapter 18, "Preventive and Screening Services" for coverage, billing, appropriate HCPCS codes, and payment requirements.  Payment is made under the Medicare Physician's Fee Schedule (MPFS) or clinical diagnostic lab fee schedule depending on the service.   80.1 - Pneum ococcal Pneumonia, Influenza Virus, and Hepatitis B Vaccines  (Rev. 1, 10- 01-03) SNF -536.2   Part B of Medicare pays 100 percent for pneumococcal pneumonia vaccines (PPV) and influenza virus vaccines and their administration.  Payment is made on a cost basis .  Deductible and coinsurance do not apply.  Part B of Medicare also covers the hepatitis B vaccine and its administration.  Deductible and coinsurance apply.   Medicare Claims Processing Manual, Chapter 18, "Preventive and Screening Services," contains ins tructions for simplified billing of Influenza virus vaccine and Pneumococcal Pneumonia vaccine by mass immunizers.   80.2 - Mammography Screening  (Rev. 3053, Issued: 08- 28-14, Effective: ICD -10: Upon Implementation of ICD -10 ASC- X12: 01- 01-12, Implementation ICD -10: Upon Implementation of ICD -10; ASC X12: 09 -30-14)  Section 4163 of the Omnibus Budget Reconciliation Act of 1990 added 1834(c) of the Act to provide for Part B  coverage of mammography screening for certain women entitled to Medicare for screenings performed on or after January 1, 1991.  The term "screening mammography" means a radiologic procedure provided to an asymptomatic woman for the purpose of early detect ion of breast cancer and includes a physician's interpretation of the results of the procedure.  Unlike diagnostic mammographies, there do not need to be signs, symptoms, or history of breast disease in order for the exam to be covered.   The technical comp onent portion of the screening mammography should be billed on the ASC X12 837 institutional claim format or if permissible Form CMS -1450 under bill type 22X for SNF Part A and Part B inpatients or 23X for SNF outpatients.  Claims for mammography screening  should include only the charges for the screening mammography.   80.2.1 - Diagnostic and Screening Mammograms Performed With New Technologies (Rev. 1, 10- 01-03)  Section 104 of the Benefits Improvement and Protection Act 2000, (BIPA) entitled "Modernization of Screening Mammography Benefit," provides for new payment methodologies for both diagnostic and screening mammograms that utilize advanced new technologies for the period April 1, 2001, through December 31, 2001.  See the Medicare Claims Processing Man ual, Chapter 18, "Preventive and Screening Services," for the payment method for this period, applicable HCPCS codes, and other billing and processing instructions.  Effective January 1, 2002, payment is based on the mammography benefit pricing file furnis hed by CMS.  80.3 - Screening Pap Smears  (Rev. 1, 10- 01-03) SNF -541.2   Sections 1861(s)(14)  and 1861(nn) of the Act, (as enacted by 6115 of the Omnibus Budget Reconciliation Act of 1989) provides for coverage of screening pap smears for services provided on or after July 1, 1990.  Screening pap smears are laboratory tests consisting of a routine exfoliative  cytology test (Papanicolaou test) provided for the purpose of early detection of cervical cancer.  It includes a collection of the sample of cells and a physician's interpretation of the test.   Payment is made under the clinical diagnostic laboratory fee schedule.   80.4 - Screening Pelvic Examinations  (Rev. 1, 10- 01-03)  Section 4102 of the BBA of 1997 (P.L.  105 -33) amended 1861(nn) of the Act (42 USC 1395X(nn)) to include coverage of screening pelvic examinations for all female beneficiaries for services provided January 1, 1998, and later.  Effective July 1, 2001, the Consolidated Appropriations Act of 2001 (P.L.  106- 554) modifies 1861(nn) to provide Medicare coverage for biennial screening pelvic examinations.   Payment is made under the Medicare Physician's Fee Schedule (MPFS).