(Medicare Claims Processing Manual)

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 receivin g 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 am bulance 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 SN F 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 transportati on 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 fo rms 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 requi red 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 charge s 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 bi lling, 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 administe red 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 i n 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 cont ained 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.