Glaucoma Screening

The Benefits Improvement and Protection Act of 2000, §102, provides annual coverage for glaucoma screening for Medicare beneficiaries with diabetes mellitus, or a family history of glaucoma, or African-Americans age 50 and over. 

Payment is made under the Medicare Physician's Fee Schedule (MPFS).

Billing for Laboratory Tests Under Part B - General

Section 1833(h)(5) of the Act (as enacted by The Deficit Reduction Act of 1984, Public Law 98-369) requires the establishment of a fee schedule for clinical diagnostic laboratory tests paid under Part B.

Section 1833g(5)(A)iii of Title XVIII provides that "in the case of a clinical diagnostic laboratory test provided under an arrangement (as defined in §1861(w)(1)) made by a hospital, critical access hospital or skilled nursing facility, payment shall be made to the hospital or skilled nursing facility."

SNFs must make arrangements under Part A and may make arrangements under Part B under which the SNF bills the intermediary and receives payment. Under this process, the SNF pays the lab for services whatever amount the SNF and the lab agree on, and the beneficiary may not be charged by the lab.

Where the SNF and a lab have entered into such an arrangement, the arrangement may include Part A only or may include Part A and Part B. Such an arrangement is voluntary on the part of both the lab and the SNF for Part B services.

In the absence of such an arrangement under Part B, the lab may bill the program for lab services furnished to residents for whom Part A cannot be paid, and for SNF outpatients, and the SNF may not bill the program for these services. Hospital labs and labs in other SNFs would bill the intermediary. Independent labs would bill the carrier.

Laboratory tests performed for the SNF's Medicare inpatients covered under Part A are included in the PPS SNF payment.

If the FI receives fee amounts for HCPCS included on both the clinical diagnostic laboratory fee schedule and the SNF extract of the MPFS, the SNF receives the amount on the laboratory fee schedule.

Bill type 22X for lab services to Part B residents and 23X for nonresidents should be used.

Neither deductible nor coinsurance applies to lab fee schedule payments

Glucose Monitoring

Medicare Part B may pay for a glucose monitoring device and related disposable supplies under its durable medical equipment benefit if the equipment is used in the home or in an institution that is used as a home.

Routine glucose monitoring of diabetics is never covered in a SNF, whether the beneficiary is in a covered Part A stay or not. Glucose monitoring may only be covered when it meets all the conditions of a covered laboratory service, including use by the physician in modifying the patient's treatment.

Epoetin (EPO) 

EPO is a biologically engineered protein which stimulates the bone marrow to make new red blood cells. Patients with anemia associated with chronic renal failure include all ESRD patients regardless of whether they are on dialysis. 

EPO is covered for the treatment of anemia for patients with chronic renal failure who are receiving dialysis when it is administered in a renal dialysis facility (RDF). 

EPO is not included in SNF PPS and may be billed separately when given in conjunction with dialysis by the Renal Dialysis Facility. It must be billed by the RDF. 

EPO is not a SNF outpatient benefit.