(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 7 - SNF Part B Billing (Including Inpatient Part B and  Outpatient Fee Schedule)  Table of Contents                                                                                                                       (Rev. 10880, 08- 06-21)  Transmittals for Chapter 7  10 - Billing for Medical and Other Health Services  10.1 -  Billing for Inpatient SNF Services Paid Under Part B  10.1.1  Editing of Skilled Nursing Facilities Part B Inpatient Services  10.2  Billing for Outpatient SNF Services  10.3 -  Determining How Much to Charge Before Billing Is Submitted  10.4 -  Charges for Services Provided in Different Accounting Years  10.5 -  General Payment Rules and Application of Part B Deductible and Coinsurance  20 - Use of Healthcare Common  Procedure Coding System (HCPCS)  30 - Billing Formats  30.1 -  Frequency of Billing for Skilled Nursing Facilities (SNFs)  30.2 -  Guidelines for Submitting Corrected Bills  40 - Billing Part B Rehabilitation Services  40.1 -  Audiologic Tests  50 - Billing Part B Radiology Services and Other Diagnostic Procedures  50.1 -  Bone Mass Measurements  60 - Billing for Durable Medial Equipment (DME), Orthotic/Prosthetic Devices, and Supplies (including Surgical Dressings)  60.1 -  Billing  60.2 -  Determining Payment and Patient Liability  60.3 -  Billing for Enteral and Parenteral Nutritional Therapy as a Prosthetic Device  70 - Drugs  70.1 -  Immunosuppressive Drugs Furnished to Transplant Patients  80 - Screening and Preventive Services  80.1 -  Pneumococcal Pneumonia, Influenza Virus, and Hepatitis B Vaccines  80.2 -  Mammography Screening  80.2.1 -  Diagnostic and Screening Mammograms Performed With New Technologies  80.3 -  Screening Pap Smears  80.4 -  Screening Pelvic Examinations  80.5 -  Prostate Cancer Screening  80.6 -  Colorectal Cancer Screening  80.7 -  Glaucoma Screening  90 - Billing for Laboratory Tests Under Part B -  General  90.1 -  Glucose Monitoring 100 -  Epoetin (EPO)  110 -  Carrier Claims Processing fo r Consolidated Billing for Physician and Non-Physician Practitioner Services Rendered to Beneficiaries in a Non -covered SNF Stay    10 - Billing for Medical and Other Health Services                               (Rev. 10880, Issued: 08- 06-21, Effective:  11-08-21, Implementation: 11- 08-21)  See Business Requirements at https://www.cms.gov/Regulations -and-Guidance/Guidance/Transmittals/Downloads/R20CP.pdf.  There are three situations in which a SNF may submit a claim for Part B services.  These are identif ied in subsections A through C below.   No bill is required when:    The patient is not enrolled under Part B;    Payment was made or will be made by the Public Health Service, VA, or other governmental entity;    Workers' compensation has paid or will pay the bi ll; or    Payment was made by liability, no -fault insurance, group health plan, or a large group health plan.   A - Beneficiaries in a Part B Inpatient Stay (Part B Residents)   A Part B inpatient stay includes services furnished to inpatients whose benefit days are exhausted, or who are not entitled to have payment made for services under Part A.  A more detailed description of services covered for beneficiaries in a Part B stay is found at 10.1  Billing for Inpatient Services Paid Under Part B.   B - Outpatient Services   Covered Part B services rendered to beneficiaries who are not inpatients of a SNF are considered SNF outpatient services.  They include the services listed in 10.1 below as well as additional services described in the Medicare Benefit Policy Manual, Chapter 8, "Coverage of Extended Care (SNF) Services Under Hospital Insurance," 80 and Medicare Benefit Policy Manual, Chapter 6, "Hospital Services Covered Under Part B."  Detailed instructions for billing are located in 10.2  Billing for Outpatient SNF Services.   C - Beneficiaries in a Part A Covered Stay   SNFs are required to consolidate billing to their intermediary for their covered Medicare inpatient service s.  However, certain services rendered to SNF inpatients are excluded from the SNF Prospective Payment System (PPS) reimbursement and are also excluded from consolidated billing by the SNF.  Those services must be billed to Part B by the rendering provider  and not by the SNF (except screening and preventive services as described in the next paragraph.)  A list of services excluded from consolidated billing is found in the Medicare Claims Processing Manual, Chapter 6, "SNF Inpatient Part A Billing," 20  20.4.   Screening and preventive services are not included in the SNF PPS amount but may be paid separately under Part B for Part A patients who also have Part B coverage.  Screening and preventive services are covered only under Part B.  Only the SNF may bi ll for screening and preventive services under Part B for its covered Part A inpatients.  Bill type 22X is used in billing screening and preventive services for beneficiaries in a covered Part A stay and for beneficiaries that are Part B residents.  TOB 23 x is used for SNF outpatients or for beneficiaries not in the SNF or DPU.  The SNF must provide the service or obtain it under arrangements.   Coverage, billing and payment guidelines are found in the Medicare Claims Processing Manual, Chapter 18, "Preventi ve and Screening Services;" Chapter 17, "Drugs and Biologicals;" and the Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Health Services," 50.4.4.2.   There are certain medical and other health services for which payment may not be m ade to a SNF.  Most of these are professional services performed by physicians and other practitioners.  These services are always billed to the Medicare Part B MAC .  Others are services that have been determined to require a hospital setting to assure ben eficiary safety.  Part A MAC shared systems receive an annual file listing these non -payable HCPCS in November, and, if necessary, a quarterly update via a one -time-only notification.   Physicians, non- physician practitioners, and suppliers billing the Part  B MAC , and providers billing the Part A MAC should consult the CMS Web site at http://www.cms.hhs.gov/SNFConsolidatedBilling/  for lists of separately billable services.    10.1 - Billing for Inpatient SNF Services Paid Under Part B  (Rev. 980, Issued: 06- 14-06, Effective: 10- 01-06, Implementation: 10- 02-06)  When the beneficiary in a Medicare- certified SNF is not entitled to Part A benefits, limited benefits are provided under Part B.  Reasons for not being entitled to have payment made under Part A are that :   The beneficiary does not have Medicare Part A Health Insurance;    The beneficiary is not in a Medicare- certified bed;    The inpatient stay is not at a covered level of care and no Part A program payment is possible; or    The inpatient stay is not covered because the beneficiary did not have a 3 -day qualifying stay.   When no Part A program payment is possible, some or all services may be medically necessary and can be covered as ancillary services under Part B.  The following services may be billed by the S NF or the rendering provider or supplier under an arrangement with the SNF:   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 funct ion 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 require d 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 15, Covered Medical and Other Health Services, 220 and 230.  Screening mammography services;   Screening pap smears;   Influenza, pneumococcal pneumonia, and hepatitis B vaccines;   Colorectal screening;   Bone mass measurements;   Diabetes self -management;   Prostate screening;   Ambulance services;   Hemophilia clotting factors for hemophilia patients competent to use these factors without supervision);   Immunosuppressive drugs;   Oral anti -cancer drugs;   Oral drug prescribed for use as an acute anti -emetic used as part of an  anti-cancer chemotherapeutic regimen; and   Epoetin Alfa (EPO).   See chapter 6 of Pub. 100- 02, Medicare Benefit Policy Manual for a discussion of the circumstances under which the above services may be covered as Part B Inpatient services.   Coverage rules f or these services are described in Pub. 100- 02, Medicare Benefit Policy Manual, Chapters 10, 14, or 15.  Specific billing instructions are found in the Medicare Claims Processing Manual, Chapters 13, 15, 16, 18, 20, or 23.  Outpatient physical therapy, out patient speech -language pathology services, and outpatient occupational therapy (see Chapter 10, 60) are billable services for SNF inpatients not in a Part A stay.  However, they must be billed by the SNF even when another entity renders the services under an arrangement with the SNF.   The determination of whether to use TOB 22x or 23x is a function of the type of facility in which the beneficiary resides.  If the facility is not Medicare -certified, it is not a SNF, although it may have a Medicare- certifi ed distinct part unit (DPU).  If the beneficiary is in a SNF or SNF DPU, Part B services must be billed on TOB 22x.  All services rendered to SNF patients residing in the non- Medicare -certified portion of an institution that is not primarily engaged in the  provision of skilled services must be billed on TOB 23x.  Beneficiaries residing in such portions of the facility are considered outpatients of the SNF for Medicare purposes.  If the entire facility qualifies as a Medic are- certified SNF, all Part B servi ces rendered to residents are billed on TOB 22x.  10.1.1 - Editing of Skilled Nursing Facilities Part B Inpatient Services  (Rev. 3481, Issued: 03- 18-16. Effective: 06- 20-16, Implementation: 06- 20-16)  Medicare pays under Part B for physicians services and  for non -physician medical and other health services listed below when furnished by a participating hospital to an inpatient of the SNF when patients are not eligible or entitled to Part A benefits or the patient has exhausted their Part A benefits.  The S SM shall edit to prevent payment on Type of Bill 22x for claims containing the revenue codes listed in the table below.   010x  011x  012x  013x  014x  015x  016x  017x  018x  019x  020x  021x  022x  023x  024x  0250  0251  0252  0253  0256  0257  0258  0259  0261  0269  0270  0273  0277  0279  029x  0339  036x  0370  0374  041x  045x  0472  0479  049x  050x  051x  052x  053x  0541  0542  0543  0544  0546  0547  0548  0549  055x  057x  058x  059x  060x  0630  0631  0632  0633  0637  064x  065x  066x  067x  068x  072x  0762  078x  079x  093x  0940  0941  0943  0944  0945  0946  0947  0949  095x  0960  0961  0962  0969  097x  098x  099x  100x  210x  310x