CMS Pub. 100-04, ch. 6, § 20.4

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 billing,

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

administered 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 SNF’s 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 SNF’s Part A resident, a vaccine that is administered for

therapeutic rather than preventive purposes would be included on the SNF’s global Part

A bill for the resident’s covered stay. Alternatively, if a vaccine is preventive in 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 SNF’s 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 contained 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 SNF’s 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.

Formerly, bone mass measurement (screening) was listed as a preventive service

excluded from SNF consolidated billing. This was incorrect. Such services are

diagnostic, not screening, procedures, and therefore are bundled into SNF PPS payment

and subject to consolidated billing.