Billing for Inpatient SNF Services Paid Under Part B

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;

• 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 anticancer chemotherapeutic regimen; and

• Epoetin Alfa (EPO).

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