Determining Payment and Patient Liability

There may be prosthetic and orthotic devices, for which the SNF would bill that are not included in the fee schedule. When fee schedule amounts are not available for a particular item, the intermediary will pay based on cost.

To determine the SNF's Part B payment, the SNF subtracts any unmet Part B deductible from the lower of the actual charge or the fee schedule amount for the item or service and multiply the remainder by 80 percent. This is the final payment. The patient's liability is the remaining 20 percent plus any deductible remaining to be met.

Billing for Enteral and Parenteral Nutritional Therapy as a Prosthetic Device

Parenteral nutritional (PEN) therapies including the necessary equipment, medical supplies and nutrients provided to an inpatient (where Part A payment cannot be made), or to individuals who are not inpatients are covered as a prosthesis under the Part B prosthetic device benefit as long as the requirements in the Coverage Manual are met, and the required documentation is submitted.

The SNF or the supplier must bill the DME MAC. The SNF or supplier should refer to the most recent HCPCS directory or billing instructions distributed by the DME MAC for current HCPCS coding information. If the SNF bills the DME MAC., it must obtain a supplier number from the National Supplier Clearinghouse and must use the ASC X12 837 professional claim format, or if permissible Form CMS-1500.

Drugs

Drugs and biologicals furnished to outpatients for therapeutic purposes that are selfadministered are not covered by Medicare unless those drugs and biologicals must be put directly into an item of durable medical equipment or a prosthetic device. Exceptions to this rule are:

• Self administered drugs administered in an emergency situation; 

• Self-administered oral versions of covered injectable cancer drugs prescribed as an anti-cancer chemotherapeutic; 

• Self-administered anti-emetic drugs; 

• Oral anti-emetic drugs as full therapeutic replacements for intravenous dosage forms as part of a chemotherapeutic regimen provided that the drug(s) be administered or prescribed by a physician for use immediately before, at, or within 48 hours after the time of administration of the chemotherapeutic agent; and • Immunosuppressive drugs furnished to transplant patients.