evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
SNF -516  These services must be provided to specific beneficiaries, either: (A) End Stage Renal Disease (ESRD) beneficiaries, or (B) beneficiaries who have elected hospice, by specific licensed Medicare providers, and are excluded from SNF PPS and consolidated billing. SNFs will not be paid for Category II.A services  (dialysis, etc.) when the SNF is the place of service.  To receive Medicare payment, these services must be provided in a renal dialysis facility.  Hospices must also be the only type of provider billing hospice services.   In transmittals for A/B MAC (A) billing that provide the annual update list of HCPCS codes affected by SNF consolidated billing, such services are referred to as Major Category II of SNF consolidated billing editing.  See 10.1 above for the link to wher e transmittals providing current lists of HCPCS codes used for edits for these types of services, known as Major Category II in SNF CB editing for A/B MACs (A).   20.2.1  Dialysis and Dialysis Related Services to a Beneficiary With ESRD (Rev.  4001, Issued: 03- 16-18, Effective: 06 -19-18, Implementation: 06- 19-18)  Beneficiaries with ESRD may receive dialysis and dialysis related services from a hospital -based or free -standing RDF, or may receive home dialysis supplies and equipment from a supplier. The following services are excluded from SNF CB:    Certain dialysis services and supplies, including any related necessary ambulance services;    Home dialysis supplies and equipment, self -care home dialysis support services, and institutional dialysis services and supplies (other than those furnished or arranged for by the SNF itself) are not included in the SNF Part A PPS rate. These services may be billed separately to the A/B MAC (A) by the ESRD facility as appropriate; dialysis supplies and equipment may be billed to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) by the supplier; and
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 Erythropoiesis Stimulating Agents (ESAs) for certain dialysis patients, subject to methods and standards for its safe and effective use (see 42 CFR 494.80(a)(2) and (a)(4), 494.90(a)(4), and 494.100) may be billed by the RDF to the A/B MAC (A), or by the r etail pharmacy to the DME MAC.   By contrast, services that fall outside the scope of the Part B dialysis benefit do not qualify for the dialysis exclusion from SNF CB. Similarly, the SNF CB exclusion described above for ESAs does not encompass situations involving their use for a non -dialysis purpose (such as ameliorating the side effects of chemotherapy treatments). The Part B dialysis benefit generally does not cover dialysis for those beneficiaries who do not have ESRD. However, an exception involves acute dialysis (HCPCS code G0491) , for patients who do not have ESRD but require dialysis temporarily following an acute kidney injury (AKI) from a severe medical trauma (such as a drug overdose or a traffic accident). In contrast to maintenance dialysis for ESRD patients (who, in the abs ence of a kidney transplant, would remain on periodic dialysis indefinitely), there is an expectation with acute dialysis that the patients own kidneys will eventually recover and resume their normal function. For services furnished on or after January 1, 2017, section 808(a) of Public Law 114- 27 added acute dialysis to the scope of the Part B dialysis benefit, thereby effectively adding such services to the scope of the dialysis exclusion from SNF CB as well.   20.2.1.1 - ESRD Services  (Rev. 1252, Issued:  05- 25-07; Effective:  10 -01-06; Implementation:  08 -27-07)  Home dialysis supplies and equipment, self -care home dialysis support services, and institutional dialysis services and supplies (other than those that are furnished or arranged for by the SNF itself) are not included in the Part A PPS payment.  They may be billed separately to the A/B MAC (A) by the hospital or ESRD facility as appropriate.
(Medicare Claims Processing Manual)
Specific coding is used to differentiate dialysis and related services that are excluded from SNF consolidated billing for ESRD beneficiaries in three cases:   1. When the services are provided in a renal dialysis facility (RDF) (including ambulance services to and from the RDF if medically necessary);   2. Home dialysis when the SNF constitutes the home of the beneficiary; and   3. When ESA drugs are used for ESRD beneficiaries in conjunction with dialysis, and given by the RDF.   Note that SNFs may not be paid for home dialysis supplies.  20.2.1.2 - Coding Applicable to Dialysis Services Provided in a Renal Dialysis Facility (RDF) or Home  (Rev. 1252, Issued:  05- 25-07; Effective:  10 -01-06; Implementation:  08 -27-07)  Providers should review Chapter 8, Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, for coding applicable to services provided in a Renal Dialysis Facility.   20.2.2 - Hospice Care for a Beneficiarys Terminal Illness  (Rev.4163, Issued: 11- 02-18, Effective: 12 -04-18, Implementation: 12 -04-18)
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20.2.2 - Hospice Care for a Beneficiarys Terminal Illness  (Rev.4163, Issued: 11- 02-18, Effective: 12 -04-18, Implementation: 12 -04-18)  Hospice care related to a beneficiarys terminal condition is excluded from SNF PPS and consolidated billing.  This is because section 1862(a)(18) of the Social Security Act (the Act) specifies that SNF consolidated billing 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 consolidated billing) would be types of services for which payment may be made under Part B  (emphasis added). Hospice services would not fall within the scope of clause (I) above because, unlike the diagnostic  and therapeutic services covered under the Part A SNF benefit (see 1862(a)(1)(A) of the Act), hospice services are palliative  (see 1862(a)(1)(C) of the Act). Hospice services also would not fall within the scope of clause (II) above, because this clause encompasses services that, if not for the enactment of consolidated billing, would be separately coverable under Part B , whereas the hospice benefit is a Part A  benefit. Hospice services for terminal conditions are identified with the following types of bill: 81X or 82X.  Services unrelated to the beneficiarys terminal condition are designated by the presence of condition code 07.  Such unrelated services are included in SNF PPS and consolidated billing.  20.3 - Other Services Excluded from SNF PPS and Consolidated Billing  (Rev. 10880, Issued: 08- 06-21, Effective: 11 -08-21, Implementation: 11- 08-21)
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The following services may be billed separately under Part B by the rendering provider, supplier, or practitioner (other than the SNF that receives the Part A PPS payment) and paid to the entity that furnished the service.  These services may be provided by any Medicare provider licensed to provide them, other than the SNF that receives the Part A PPS payment, and are excluded from Part A PPS payment and the requirement for consolidated billing, and are referred to as Major Category III for consolidated billing edits applied to claims submitted to A/B MACs (A).    A medically necessary ambulance trip (other than a transfer to another SNF) that transports a beneficiary to the SNF for the initial admission or from the SNF following a final discharge, or that occurs pursuant to the offsite provision of Part B dialysis services (see section 20.3.1 for additional situations involving ambulance transportation);
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 Certain chemotherapy (that is, anti -cancer) drugs.  The chemotherapy exclusion applies solely to the particular chemotherapy codes designated under Major Category III.A of the SNF websites A/B MAC (A) Annual Update.  These same codes also appear on the li st of exclusions in File 1 of the SNF websites A/B MAC (B) Annual Update (though not displayed as a separate subcategory).  The excluded chemotherapy codes serve to identify those high- intensity chemotherapy drugs that are not typically administered in a SNF, are exceptionally expensive, or require special staff expertise to administer.  By contrast, chemotherapy drugs that are relatively inexpensive and are administered routinely in SNFs do not qualify for this exclusion and, thus, remain subject to SNF C B.  Further, this exclusion would not encompass any related items that, while commonly furnished in conjunction with chemotherapy, are not themselves inherently chemotherapeutic in nature (that is, they specifically address the side effects of the chemothe rapy rather than actively fighting the cancer itself).  Examples of such chemotherapy -related drugs would include anti -emetics (anti -nausea drugs), as well as drugs that function as an adjunct to an anti -emetic, such as an anti -anxiety drug that helps to relieve anticipatory nausea.  Even when furnished in conjunction with a chemotherapy drug that is itself excluded (and, thus, separately payable under Part B), these related drugs would remain subject to SNF CB.  Similarly, if a drug designated by one of the excluded chemotherapy codes is prescribed for a use that is not actually associated with fighting cancer, it would no longer be considered an excluded chemotherapy drug in such an instance, because it is not being used for a chemotherapeutic purpose within the meaning of this exclusion.   Certain chemotherapy administration services.  The chemotherapy administration codes are included in SNF PPS payment for beneficiaries in a Part A stay when performed alone or with other surgery, but are excluded if they occur with the same line item date of service as an excluded chemotherapy agent.  A chemotherapy agent must also be billed when billing these services, and physician orders must exist to support the provision of chemotherapy;    Certain radioisotope services;    Certain customized prosthetic devices (see 10);
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 Certain radioisotope services;    Certain customized prosthetic devices (see 10);    Effective for items and services furnished on or after October 1, 2021, certain blood clotting factors indicated for the treatment of hemophilia and other bleeding disorders;    The transportation costs of electrocardiogram equipment (HCPCS code R0076), but only with respect to those for electrocardiogram test services furnished during 1998; and   All services  provided to risk- based MCO beneficiaries.  These beneficiaries may be identified with a label attached to their Medicare card and/or a separate health insurance card from an MCO indicating all services must be obtained or arranged through the MCO (as note d previously in 10, consolidated billing applies only to Medicare fee -for-service beneficiaries).   The HCPCS code ranges for chemotherapy, chemotherapy administration, radioisotopes, customized prosthetic devices, and blood clotting factors are set in statute.  The statute also gives the Secretary authority to make modifications in the particular codes that are designated for exclusion within each of these service categories.  See 10.1 above for the link to where transmittals providing current lists of HCPCS codes used for Major Category III SNF consolidated billing editing for A/B MACs (A) can be found.  20.3.1 - Ambulance Services  (Rev. 10880, Issued: 08- 06-21, Effective: 11 -08-21, Implementation: 11- 08-21)  The following ambulance transportation and related ambulance services for residents in a Part A stay are not included in the Part A PPS payment.  Except for specific exclusions, consolidated billing includes those medically necessary ambulance trips that are furnished during the course of a covered Part A stay.  A/B MACs (A), (B), (HHH), and DME MACs are responsible for assuring that payment is made only for ambulance services that meet established coverage criteria.
(Medicare Claims Processing Manual)
In most cases, ambulance trips are excluded from consolidated billing when resident status has ended.  The ambulance company then must bill the A/B MAC (A), (B), or (HHH), or DME MAC (as appropriate) directly for payment.  Listed below are a number of spec ific circumstances under which a beneficiary may receive ambulance services that are covered by Medicare, but excluded from consolidated billing.   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
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 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:
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 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.
(Medicare Claims Processing Manual)
 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.
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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)
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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.
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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.)