Immunosuppressive Drugs Furnished to Transplant Patients

Part B of Medicare covers FDA-approved immunosuppressive drugs. Payment is made for those immunosuppressive drugs that have been specifically labeled as such and approved for marketing by the FDA, as well as those prescription drugs, such as prednisone, that are used in conjunction with immunosuppressive drugs as part of a therapeutic regimen reflected in FDA-approved labeling for immunosuppressive drugs. Therefore, antibiotics, hypertensives, and other drugs that are not directly related to rejection are not covered.

Deductible and coinsurance apply. SNFs bill using TOB 22X for Part B residents and TOB 23x for outpatients.

Screening and Preventive Services

Screening and preventive services are only covered as a Medicare Part B benefit. When furnished to a beneficiary in a SNF Part A covered stay, the SNF must bill its intermediary using 22X type of bill. These services are billed on TOB 23x for SNF outpatients and beneficiaries outside the Medicare-certified SNF or DPU.

A SNF may bill screening and preventive services for its Part B residents using 22X type of bill or the supplier may bill its carrier. Screening and preventive services rendered to SNF outpatients may be billed with 23X type of bill or the supplier may bill its carrier.

Payment is made under the Medicare Physician's Fee Schedule (MPFS) or clinical diagnostic lab fee schedule depending on the service

Pneumococcal Pneumonia, Influenza Virus, and Hepatitis B Vaccines

Part B of Medicare pays 100 percent for pneumococcal pneumonia vaccines (PPV) and influenza virus vaccines and their administration. Payment is made on a cost basis. Deductible and coinsurance do not apply. Part B of Medicare also covers the hepatitis B vaccine and its administration. Deductible and coinsurance apply.

Mammography Screening

Section 4163 of the Omnibus Budget Reconciliation Act of 1990 added §1834(c) of the Act to provide for Part B coverage of mammography screening for certain women entitled to Medicare for screenings performed on or after January 1, 1991. The term "screening mammography" means a radiologic procedure provided to an asymptomatic woman for the purpose of early detection of breast cancer and includes a physician's interpretation of the results of the procedure. Unlike diagnostic mammographies, there do not need to be signs, symptoms, or history of breast disease in order for the exam to be covered.

The technical component portion of the screening mammography should be billed on the ASC X12 837 institutional claim format or if permissible Form CMS-1450 under bill type 22X for SNF Part A and Part B inpatients or 23X for SNF outpatients. Claims for mammography screening should include only the charges for the screening mammography.