evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
A SNF may  not bill for DME furnished to its Part A inpatients as necessary DME must be supplied to the beneficiary as part of SNF services.  A SNF may not bill for DME furnished to its Part B inpatients or outpatients.  However, a SNF may qualify as a supplier and enroll with the National Supplier Clearinghouse.  In such cases, the SNF is given a separate supplier number to bill outpatient DME to the DME MAC.  The DME MAC will furnish billing guidelines and payment will be made directly to the SNF as a supplier.  The SNF or other entity that furnishes prosthetic and/or orthotic devices to SNF residents for whom Part A benefits are not payable (no Part A entitlement or benefits exhausted) and for SNF outpatients may bill for such items.  The SNF bills the A/B MAC (A ).  Suppliers bill the A/C MAC (B) or DME MAC.  See Chapter 20 for DMEPOS billing requirements, including definition of "supplier."   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)
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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).   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
(Medicare Claims Processing Manual)
 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)
(Medicare Claims Processing Manual)
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."
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual Crosswalk)
Medicare Claims Processing Manual  Chapter 7 - SNF Part B Billing (Including Inpa tient Part B and Outpatient Fee Schedule) Crosswalk Chap.                    Sect. SNFPub 12 Carrier Pub 14. PMs Other Description7 10 SNF-529    Billing for Medical and Other Health Services 7 10.1   A-03-040  Clarifies the use of TOBs 22x and 23x submitted by SNFs. 7a 10.2 SNF - 529    Billing for Medical & Other Health Services 7 10.3 SNF-529.1    Determining How Much to Charge Before Billing Is Submitted 7 10.4 SNF-529.2    Charges for Services Provided in Different Accounting Years 7 10.5 SNF-529.3    General Payment Rules and Application of Part B Deductible and Coinsurance 7 20 SNF-530,SNF-530.3    Use of Healthcare Common Procedure Coding System (HCPCS) 7 30 Billing Formats7 30.1 SNF-561    Frequency of Billing for SNFs 7 30.2 SNF-562,SNF-562A    Guidelines for Submitting Corrected Bills Chap. Sect. SNF Pub 12 Carrier Pub 14. PMs Other Description