CMS Pub. 100-04, ch. 7, § 10.1

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 SNF 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 function 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 required because of

breakage, wear, loss, or a change in the patient’s 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 for 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, outpatient 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-certified 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 services rendered to

residents are billed on TOB 22x.