Billing for Outpatient SNF Services

Coverage is available for all of the services described in §10.1. However, beneficiaries not in the Medicare-certified Distinct Part Unit (DPU) are not required to have therapy services (physical therapy, occupational therapy, and speech language pathology) billed by the SNF. Therapy services need only be bundled to the SNF for those SNF residents in a Medicare-certified DPU.

Determining How Much to Charge Before Billing Is Submitted 

The SNF may be able to determine from the SNF's records, from a transferring hospital, or from the patient the extent to which the Part B cash deductible is met. The SNF may charge the patient for the unmet deductible and coinsurance. The SNF should submit a bill even if no payment can be made because the unmet Part B cash deductible exceeds the covered charges. In addition, a bill is required when the SNF becomes aware that no bill has been submitted for covered services even though the time limitation for filing has expired.

Charges for Services Provided in Different Accounting Years

The SNF must not put charges for services provided in different accounting years on the same bill. At the end of the SNF's accounting year, the SNF should submit a bill that contains the charges for all services furnished to the patient since the last bill through the end of the year. The SNF should include bills in which the deductible covers all charges. All services furnished in the succeeding accounting year should be placed on a separate bill. Complete all items on the subsequent bill.

General Payment Rules and Application of Part B Deductible and Coinsurance

Section 1888(e)(9) of the Social Security Act (the Act) requires that the payment amount for Part B SNF services shall be the amount prescribed in the otherwise applicable fee schedule. Thus, where a fee schedule exists for the type of service, the fee amount will be paid. Where a fee does not exist on the Medicare Physician Fee Schedule (MPFS) the particular service is priced based on cost. This is also true for all “carrier-priced” codes on the MPFS, but not for services paid on the Clinical Diagnostic Laboratory Fee Schedule. All lab services missing fees are to be gap-filled. Some specific services continue to be paid on a cost basis and are specifically stated in the sections below where cost applies.

Where payment is made under a fee schedule, the beneficiary's deductible and coinsurance are based on the approved amount. Where payment is made on a cost basis, deductible and coinsurance are based on charges for the service.