CMS Pub. 100-04, ch. 7, § 10

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 identified 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 bill; 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 services. 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 bill

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 23x 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, "Preventive 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 made

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 beneficiary

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.