100-04 Medicare Claims Processing Manual: Chapter 6 - Inpatient Part A Billing and SNF Consolidated Billing

Medicare Claims Processing Manual
Chapter 6 - SNF Inpatient Part A Billing and SNF
Consolidated Billing
Table of Contents
(Rev. 13089; Issued: 02-21-25)
Transmittals for Chapter 6
10 - Skilled Nursing Facility (SNF) Prospective Payment System (PPS) and Consolidated
Billing Overview
10.1 - Consolidated Billing Requirement for SNFs
10.2 - Types of Facilities Subject to the Consolidated Billing Requirement for
SNFs
10.3 - Types of Services Subject to the Consolidated Billing Requirement for
SNFs
10.4 - Furnishing Services that are Subject to SNF Consolidated Billing Under an
“Arrangement” with an Outside Entity
10.4.1 - “Under Arrangements” Relationships
10.4.2 - SNF and Supplier Responsibilities
20 - Services Included in Part A PPS Payment Not Billable Separately by the SNF
20.1 - Services Beyond the Scope of the Part A SNF Benefit
20.1.1 - Physician’s Services and Other Professional Services Excluded
From Part A PPS Payment and the Consolidated Billing Requirement
20.1.1.1 - Correct Place of Service (POS) Code for SNF Claims
20.1.1.2 - Hospital’s “Facility Charge” in Connection with Clinic
Services of a Physician
20.1.2 - Other Excluded Services Beyond the Scope of a SNF Part A
Benefit
20.1.2.1 - Outpatient Surgery and Related Procedures- Inclusion
20.1.2.2 - Emergency Services
20.2 - Services Excluded from Part A PPS Payment and the Consolidated Billing
Requirement on the Basis of Beneficiary Characteristics and Election
20.2.1 - Dialysis and Dialysis Related Services to a Beneficiary With
ESRD
20.2.1.1 - ESRD Services
20.2.1.2 - Coding Applicable to Dialysis Services Provided in a
Renal Dialysis Facility (RDF) or Home)
20.2.2 - Hospice Care for a Beneficiary’s Terminal Illness

20.3 - Other Services Excluded from SNF PPS and Consolidated Billing
20.3.1 - Ambulance Services
20.4 - Screening and Preventive Services
20.5 - Therapy Services
20.6 - SNF CB Annual Update Proces for A/B MACs (A)
30 - Billing SNF PPS Services
30.1 - Health Insurance Prospective Payment System (HIPPS) Rate Code
30.2 - Coding PPS Bills for Ancillary Services
30.3 - Adjustment Request
30.4 - SNF PPS Pricer Software
30.5 - Annual Updates to the SNF Pricer
40 - Special Inpatient Billing Instructions
40.1 - Submit Bills in Sequence
40.2 - Reprocessing Inpatient Bills in Sequence
40.3 - Determining Part A Admission Date, Discharge Date, and Utilization Days
40.3.1 - Date of Admission
40.3.2 - Patient Readmitted Within 30 Days After Discharge
40.3.3 - Same Day Transfer
40.3.4 - Situations that Require a Discharge or Leave of Absence
40.3.5 - Determine Utilization on Day of Discharge, Death, or Day
Beginning a Leave of Absence
40.3.5.1 - Day of Discharge or Death Is the Day Following the
Close of the Accounting Year
40.3.5.2 - Leave of Absence
40.4 - Accommodation Charges Incurred in Different Accounting Years
40.5 - Billing Procedures for Periodic Interim Payment (PIP) Method of Payment
40.6 - Total and Noncovered Charges
40.6.1 - Services in Excess of Covered Services
40.6.2 - Showing Discounted Charges
40.6.3 - Reporting Accommodations on the Claim
40.6.4 - Bills with Covered and Noncovered Days
40.6.5 - Notification of Limitation on Liability Decision
40.7 Ending a Benefit Period
40.8 - Billing in Benefits Exhaust and No-Payment Situations
40.8.1 - SNF Spell of Illness Quick Reference Chart
40.8.2 - Billing When Qualifying Stay or Transfer Criteria are Not Met
40.9- Other Billing Situations
50 - SNF Payment Bans, or Denial of Payment for New Admissions (DPNA)
50.1 - Effect on Utilization Days and Benefit Period

50.2 - Billing When Ban on Payment Is In Effect
50.2.1 - Effect of an Appeal to a DPNA on Billing Requirements During
the Period a SNF is Subject to a DPNA
50.2.2 - Provider Liability Billing Instructions
50.2.3 - Beneficiary Liability Billing Instructions
50.2.4 - Part B Billing
50.3 - Sanctions Lifted: Procedures for Beneficiaries Admitted During the
Sanction Period
50.3.1 - Tracking the Benefit Period
50.3.2 - Determining Whether Transfer Requirements Have Been Met
50.4 - Conducting Resident Assessments
50.5 - Physician Certification
50.6 - A/B MAC (A) Responsibilities
50.7 - Retroactive Removal of Sanctions
60 - Billing Procedures for a Composite SNF or a Change in Provider Number
70 - Billing for Services After Termination of Provider Agreement, or After Payment is
Denied for New Admissions
70.1 - General Rules
70.2 - Billing for Covered Services
70.3 - Part B Billing
80 - Billing Related to Physician’s Services
80.1 - Reassignment Limitations
80.2 - Payment to Employer of Physician
80.3 - Information Necessary to Permit Payment to a Facility
80.4 - Services Furnished Within the SNF
80.5 - Billing Under Arrangements
80.6 - Indirect Contractual Arrangement
80.7 - Establishing That a SNF Qualifies to Receive Part B Payment on the Basis
of Reassignment
90 - Medicare Advantage (MA) Beneficiaries
90.1 - Beneficiary Disenrolled from MA Plans
90.2 - Medicare Billing Requirements for Beneficiaries Enrolled in MA Plans
100 - Part A SNF PPS for Hospital Swing Bed Facilities
100.1 - Swing Bed Services Not Included in the Part A PPS Rate
110 - A/B MAC (B)/DME MAC Claims Processing for Consolidated Billing for
Physician and Non-Physician Practitioner Services Rendered to Beneficiaries in a SNF
Part A Stay
110.1 - Correct Place of Service (POS) Code for SNF Claims
110.2 - CWF Edits
110.2.1 - Reject and Unsolicited Response Edits

110.2.2 - A/B Crossover Edits
110.2.3 - Duplicate Edits
110.2.4 - Edit for Ambulance Services
110.2.5 - Edit for Clinical Social Workers (CSWs)
110.2.6 - Edit for Therapy Services Separately Payable When Furnished
by a Physician
110.2.7 - Edit to Prevent Payment of Facility Fees for Services Billed by
an Ambulatory Surgical Center (ASC) when Rendered to a Beneficiary in
a Part A Stay
110.3 - CWF Override Codes
110.4 - Coding Files and Updates
110.4.1 - Annual Update Process
120- Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)
120.1 - HIPPS Updates and Structure Changes
120.2 - Interrupted Stay Policy
120.3 - Variable Per Diem (VPD) Adjustment
120.4 - AIDS Adjustments
120.5 - Transition Claims
120.6 - Default Billing

10 - Skilled Nursing Facility (SNF) Prospective Payment System (PPS)
and Consolidated Billing Overview
(Rev.4163, Issued: 11-02-18, Effective: 12-04-18, Implementation: 12-04-18)
All SNF Part A inpatient services are paid under a prospective payment system (PPS).
Under SNF PPS, beneficiaries must meet the regular eligibility requirements for a SNF
stay. That is, the beneficiary must have been an inpatient of a hospital for a medically
necessary stay of at least three consecutive calendar days. In addition, the beneficiary
must have been transferred to a participating SNF within 30 days after discharge from the
hospital, unless the patient’s condition makes it medically inappropriate to begin an
active course of treatment in an SNF within 30 days after hospital discharge, and it is
medically predictable at the time of the hospital discharge that the beneficiary will
require covered care within a predetermined time period. (See the Medicare Benefit
Policy Manual, Chapter 8, “Coverage of Extended Care Services Under Hospital
Insurance,” §20.2, for further information on the 30-day transfer requirement and
exception.) To be covered, the extended care services must be needed for a condition
which was treated during the patient’s qualifying hospital stay, or for a condition which
arose while in the SNF for treatment of a condition for which the beneficiary was
previously treated in a hospital.
Also under SNF PPS all Medicare covered Part A services that are considered within the
scope or capability of SNFs are considered paid in the PPS rate. In some cases this
means that the SNF must obtain some services that it does not provide directly. Neither
the SNF nor another provider or practitioner may bill the program for the services under
Part B, except for services specifically excluded from PPS payment and associated
consolidated billing requirements.
Any DME or oxygen furnished to inpatients in a covered Part A stay is included in the
SNF PPS rate. The definition of DME in §1861(n) of the Social Security Act (the Act)
provides that DME is covered by Part B only when intended for use in the home, which
explicitly does not include a SNF. This definition applies to oxygen also. (See the
Medicare Benefit Policy Manual, Chapter 15, “Covered Medical and Other Health
Service,” §110.)
Most prosthetics and all orthotic devices are included in the Part A PPS rate. An
exception involves certain designated customized prosthetic devices that are specifically
identified as being outside the rate (see the regulations at 42 CFR 411.15(p)(2)(xvi) and
Major Category III.D of the SNF consolidated billing editing). Those customized
prosthetic devices that are considered outside the PPS rate are billed by the qualified
outside entity that furnished the service. That entity bills its normal MAC.
Services that are not considered to be furnished within SNF PPS are identified in sections
§§20.1 - 20.4. These may be billed separately under Part B. Some services must be
billed by the SNF. (This is referred to as “consolidated billing.”) Some services must be
billed by the rendering provider (SNF or otherwise). These are discussed further in
§§20.1 - 20.4.

10.1 - Consolidated Billing Requirement for SNFs
(Rev.4163, Issued: 11-02-18, Effective: 12-04-18, Implementation: 12-04-18)
Section 4432 (b) of the Balanced Budget Act (BBA) requires consolidated billing (CB)
for SNFs. Under the CB requirement, the SNF must submit ALL Medicare claims for
ALL the services that its residents receive under Part A, except for certain excluded
services described in §§20.1 - 20.3, and for all physical, occupational and speech-
language pathology services received by residents under Part B (see §20.5). A SNF
resident is defined as a beneficiary who is admitted to a Medicare participating SNF or
the participating, Medicare-certified, distinct part unit (DPU) of a larger institution.
Under the regulations at 42 CFR 411.15(p)(3)(i)-(iv), if such a beneficiary leaves the
facility (or the DPU), the beneficiary’s status as a SNF “resident” for CB purposes (along
with the SNF’s responsibility to furnish or make arrangements for needed services) ends
when any one of the following events occurs:
• 	The beneficiary is admitted as an inpatient to a Medicare-
participating hospital or critical access hospital (CAH), or as a
resident to another SNF;
• 	The beneficiary receives services from a Medicare-participating
home health agency under a plan of care;
• The beneficiary receives one of the types of outpatient hospital
services that CMS has designated as being exceptionally intensive
(see §20.1.2); or
• The beneficiary is formally discharged (or otherwise departs) from
the SNF or DPU, unless the beneficiary is readmitted (or returns)
to that or another SNF before the following midnight. This
provision is sometimes referred to as the “midnight rule” (see Pub.
100-02, Medicare Benefit Policy Manual, chapter 3, §20.1, which
specifies that an inpatient day “. . . begins at midnight and ends 24
hours later”). A “discharge” from the Medicare-certified DPU
includes situations in which the beneficiary is moved from the
DPU to a Medicare non-certified area within the same institution.
When a beneficiary is absent from the SNF overnight (i.e., the absence from the SNF
spans midnight), the beneficiary’s status as a SNF “resident” for CB purposes would end
upon the point of departure from the SNF (per the above-described “midnight rule”), and
would not resume until the actual point of arrival back at the SNF the next day.
Accordingly, that beneficiary would not be considered a SNF “resident” for CB purposes
between those two points, so that any offsite services furnished during the interim (such
as an overnight sleep study) would not be subject to CB.
It should be noted that the scenarios described in the first three clauses above would
become relevant only if a beneficiary leaves the SNF but then arrives back in that or

another SNF before the following midnight. This is because under the “midnight rule”
discussed in the fourth clause, whenever a beneficiary leaves the SNF but does not arrive
back in that or another SNF later on that same day, the beneficiary’s “resident” status for
CB purposes would end immediately upon departure--before any of the other events
described in the first three clauses could even occur.
By contrast, when a beneficiary does return to that or another SNF by the end of the same
day (a scenario that normally would serve to maintain the beneficiary’s status as a
“resident” of the originating SNF throughout the absence), the occurrence of one of the
intervening events listed in the first three clauses above would nevertheless serve to end
the beneficiary’s “resident” status at that point. For example, when a beneficiary leaves
the SNF to receive outpatient emergency services at the hospital, the emergency services
would never be subject to CB—even in a situation where the beneficiary returns to the
SNF later that same day—because the receipt of the emergency services themselves
under the third clause above would have already served to suspend the beneficiary’s SNF
“resident” status with respect to those services under the regulations at 42 CFR
411.15(p)(3)(iii).
These requirements apply only to Medicare fee-for-service beneficiaries residing in a
participating SNF or DPU.
Claims are submitted to the A/B MAC (A) on the ASC X12 837 institutional format or
Form CMS-1450. All services billed by the SNF (including those furnished under
arrangements with an outside supplier) for a resident of a SNF in a covered Part A stay
are included in the SNF’s Part A bill. If a resident is not in a covered Part A stay (Part A
benefits exhausted, posthospital or level of care requirements not met), the SNF is
required to bill for all physical therapy, occupational therapy, and/or speech-language
pathology services provided to a SNF resident under Part B. The CB provision requires
that effective for services and items furnished on or after July 1, 1998, payment is made
directly to the SNF.
Thus, SNFs are no longer able to “unbundle” services to an outside supplier that can then
submit a separate bill directly to an A/B MAC (B) or DME MAC for residents in a Part A
stay, or for SNF residents receiving physical therapy, occupational therapy, and/or
speech-language pathology services paid under Part B. Instead, the SNF must furnish the
services either directly or under an arrangement with an outside supplier or provider of
services in which the SNF (rather than the supplier or provider of services) bills
Medicare. Medicare does not pay amounts that are due a provider to any other person
under assignment, or power of attorney, or any other direct payment arrangement. As a
result, the outside supplier must look to the SNF (rather than the A/B MAC (A), or (B),
or DME MAC or the beneficiary) for payment. The SNF may collect any applicable
deductible or coinsurance from the beneficiary.
NOTE: The requirements for participation at 42 CFR 483.15(c)(1)(i)(A)-(F) specify the
limited circumstances under which a resident can be involuntarily moved out of a
Medicare-certified SNF or DPU. These circumstances can include situations in which
the resident's health has improved to the point where he or she no longer needs SNF care.

However, if a resident has exhausted Part A benefits but nevertheless continues to require
SNF care, he or she cannot be moved out of the Medicare-certified SNF or DPU for
reasons other than those specified in the regulations. For example, the resident cannot be
moved to avoid the CB requirements, or to establish a new benefit period. The
determination to move the beneficiary out of the SNF or DPU must not be made on the
basis of the beneficiary having exhausted his or her benefits, but rather, on the
beneficiary's lack of further need for SNF care. Once a resident of a Medicare-certified
DPU ceases to require SNF care, he or she may then be moved from the DPU to the
Medicare non-certified area of the institution. As discussed above, such a move would
end the beneficiary's status as a SNF "resident" for CB purposes.
Enforcement of CB is done through editing in Medicare claims processing systems using
lists of Healthcare Common Procedure Coding System (HCPCS) codes that are subject to
the CB provision of SNF PPS. In order to assure proper payment in all settings,
Medicare systems must edit for services, provided to SNF beneficiaries, both included
and excluded from CB. Transmittals with instructions provide updates to previous lists
of the exclusions, and some inclusions, to CB. Such transmittals can be found on the
CMS Web site at: https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html or
http://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html. Step-by-step
instructions for accessing the exclusion list itself appear in the Medicare Benefit Policy
Manual, Chapter 8, §10.2.
The list of HCPCS codes enforcing CB may be updated each quarter. For the notice on
CB for the quarter beginning January, separate instructions are published for A/B MACs
(A) and A/B MACs (B)/DME MACs. Since this is usually the only quarter in which new
permanent HCPCS codes are produced, this recurring update is referred to as an annual
update. Other updates for the remaining quarters of the year will occur as needed prior to
the next annual update. In lieu of another update, editing based on the prior list of codes
remains in effect. Some non-January quarterly updates may apply to each of A/B MACs
(A) and (HHH) and A/B MACs (B)/DME MACs, and the applicability of the instruction
will be clear in each update. All future updates will be submitted via a Recurring Update
Notification form.
• 	Effective July 1, 1998, CB became effective for those services and items that were
not specifically excluded by law from the SNF prospective payment system (PPS)
when they were furnished to residents of a SNF in a covered Part A stay and also
includes physical therapy, occupational therapy, and/or speech-language pathology
services in a noncovered stay. SNFs became subject to CB once they transitioned
to PPS. Due to systems limitations, CB was not implemented at that time for
residents not in a Part A covered stay (Part A benefits exhausted, post-hospital or
level of care requirements not met). Section 313 of the Benefits Improvement and
Protection Act (BIPA) of 2000 subsequently repealed this aspect of CB altogether,
except for physical therapy, occupational therapy, and/or speech-language
pathology services. In addition, for either type of resident, the following
requirements were also delayed: (1) that the physicians forward the technical

portions of their services to the SNF; and (2) the requirement that the physician
enter the facility provider number of the SNF on the claim.
• 	Effective July 1, 1998, under 42 CFR 411.15(p)(3)(iii) published on May 12,
1998, a number of other services are excluded from CB. The hospital outpatient
department will bill these services directly to the A/B MAC (A) when furnished on
an outpatient basis by a hospital or a critical access hospital (see §20.1.2).
Physician’s and other practitioner’s professional services will be billed directly to
the A/B MAC (B) (see §20.1.1). Hospice care (see §20.2.2) and the ambulance
trip that initially conveys an individual to the SNF to be admitted as a resident, or
that conveys an individual from the SNF when discharged and no longer
considered a resident (see §20.3), are also excluded from CB.
• 	Effective April 1, 2000, §103 of the Balanced Budget Refinement Act (BBRA)
excluded additional services and drugs from CB that therefore had to be billed
directly to the A/B MAC (B) or DME MAC by the provider or supplier for
payment (see §20.3). As opposed to whole categories of services being excluded,
only certain specific services and drugs (identified by HCPCS code) were excluded
in each category. These exclusions included ambulance services furnished in
conjunction with renal dialysis services, certain specific chemotherapy drugs and
their administration services, certain specific radioisotope services, and certain
customized prosthetic devices.
• 	Effective January 1, 2001, §313 of the BIPA, restricted CB to the majority of
services provided to beneficiaries in a Medicare Part A covered stay and only to
therapy services provided to beneficiaries in a noncovered stay (see §20.5).
• 	Effective for claims with dates of service on or after April 1, 2001, for
those services and supplies that were not specifically excluded by law and
are furnished to a SNF resident covered under the Part A benefit,
physicians are required to forward the technical portions of any services to
the SNF to be billed by the SNF to the A/B MAC (A) for payment (see
§20.1.1).
10.2 - Types of Facilities Subject to the Consolidated Billing
Requirement for SNFs
(Rev. 4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11- 05-19)
Consolidated billing applies to:
• 	Participating SNFs;
• 	Short term hospitals, long term hospitals, and rehabilitation hospitals certified as
swing-bed hospitals, except critical access hospitals (CAHs) certified as swing
bed hospitals (however, while a CAH’s SNF-level swing bed services are not
subject to consolidated billing, they remain subject to the bundling requirement
for hospitals, as specified in the Medicare Claims Processing Manual, Chapter 3,
§60). Rural (non-CAH) swing bed hospitals that furnish SNF-level services are

subject to both the consolidated billing and hospital bundling requirements (see
§100.1); accordingly, as explained in the FY 2002 SNF PPS final rule (66 FR
39593, July 31, 2001), for the small number of services (such as dialysis) that are
excluded from consolidated billing but remain subject to hospital bundling, the
billing responsibility would remain with the rural swing bed hospital itself (in
accordance with the hospital bundling requirement), but it would use a separate
inpatient Part B claim to bill for those services outside of the bundled SNF PPS
rate (in recognition of their exclusion from the consolidated billing requirement).
But consolidated billing does not apply to:
• 	A nursing home that is not Medicare-certified, such as:
o 	A nursing home that does not participate at all in either the Medicare or
Medicaid programs;
o 	A non-certified part of a nursing home that also includes a participating
distinct part SNF unit; and
o 	A nursing home that exclusively participates in the Medicaid program as
an NF.
• 	CAHs certified as swing-bed hospitals. However, as noted above, CAH swing-
bed services are subject to the hospital bundling requirement at section
1862(a)(14) of the Social Security Act and 42 CFR § 411.15(m).
Medicare Coordinated Care Demonstration
Services for beneficiaries covered under the Medicare Coordinated Care Demonstration
will not be subject to consolidated billing. Common Working File (CWF) will
appropriately edit for these codes so that the A/B MACs (B) will pay them separately.
10.3 - Types of Services Subject to the Consolidated Billing
Requirement for SNFs
(Rev. 2573, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13)
As previously discussed, the consolidated billing requirement applies to all services
furnished to a SNF resident in a covered Part A stay (other than the excluded service
categories described below) and for physical therapy, occupational therapy, and/or
speech-language pathology services provided to residents and paid under Part B.
Examples of services that are subject to consolidated billing include:
• 	Physical therapy, occupational therapy, and/or speech-language pathology
services, regardless of whether they are furnished by (or under the supervision of)

a physician or other health care professional (see §1888(e)(2)(A)(ii) of the Act).
Physical therapy, occupational therapy, and/or speech-language pathology
services (other than audiology services, which are considered diagnostic tests
rather than therapy services) furnished to a SNF resident during a noncovered stay
must still be billed by the SNF itself. This is known as “Part B” consolidated
billing (see §20.5 of this chapter).
• 	Psychological and other services furnished by a clinical social worker; and
• 	Services furnished as an “incident to” the professional services of a physician or
other excluded category of health care professional described in §20.1.1 below.
10.4 - Furnishing Services that are Subject to SNF Consolidated Billing
Under an “Arrangement” With an Outside Entity
(Rev .4001, Issued: 03-16-18, Effective: 06- 19- 18, Implementation: 06-19-18)
As discussed in §10.1 and §10.3, the SNF consolidated billing provisions (at
§1862(a)(18), §1866(a)(1)(H)(ii), and §1888(e)(2)(A) of the Act) place with the SNF
itself the Medicare billing responsibility for most of its residents’ services. “Part A”
consolidated billing requires that a SNF must include on its Part A bill almost all of the
services that a resident receives during the course of a Medicare-covered stay, other than
those services that are specifically excluded from the SNF’s global PPS per diem
payment for the covered stay. (These “excluded” services, such as the services of
physicians and certain other practitioners, remain separately billable to the A/B MAC (B)
directly by the outside entity that actually furnishes them.) In addition, “Part B”
consolidated billing makes the SNF itself responsible for submitting the Part B bills for
any physical therapy, occupational therapy, and/or speech-language pathology services
that a resident receives during a noncovered stay (see §20.5).
Further, for any Part A or Part B service that is subject to SNF consolidated billing, the
SNF must either furnish the service directly with its own resources, or obtain the service
from an outside entity (such as a supplier) under an “arrangement,” as described in
§1861(w) of the Act and in §80.5. Under such an arrangement, the SNF must reimburse
the outside entity for those Medicare-covered services that are subject to consolidated
billing; i.e., services that are reimbursable only to the SNF as part of its global PPS per
diem or those Part B services that must be billed by the SNF.
Since the inception of the SNF PPS, several problematic situations have been identified
where the SNF resident receives services that are subject to consolidated billing from an
outside entity, such as a supplier. (In this context, the term “supplier” can also include
those practitioners who, in addition to performing their separately billable professional
services, essentially act as a supplier by also furnishing other services that are subject to
the consolidated billing requirement.) As discussed in greater detail below, such
situations most commonly arise in one of the following two scenarios: 1) A SNF does

not accurately identify services as being subject to consolidated billing when ordering
such services from a supplier or practitioner; or 2) A supplier fails to ascertain a
beneficiary’s status as a SNF resident when the beneficiary (or another individual acting
on the beneficiary’s behalf) seeks to obtain such services directly from the supplier
without the SNF’s knowledge.
The absence of a valid arrangement in the situations described above creates confusion
and friction between SNFs and their suppliers. Suppliers need to understand which
services are subject to consolidated billing to avoid situations where they might
improperly attempt to bill the A/B MAC (B) (or other payers such as Medicaid and
beneficiaries) directly for the services. In addition, when ordering or furnishing services
“under arrangements,” both parties need to reach a common understanding on the terms
of payment; e.g., how to submit an invoice, how payment rates will be determined, and
the turn-around time between billing and payment. Without this understanding, it may
become difficult to maintain the strong relationships between SNFs and their suppliers
that are necessary to ensure proper coordination of care to the Medicare beneficiaries.
Whenever possible, SNFs should document arrangements with suppliers in writing,
particularly with suppliers furnishing services on an ongoing basis, such as laboratories,
x-ray suppliers, and pharmacies. This also enables the SNF to obtain the supplier’s
assurance that the arranged-for services will meet accepted standards of quality (under
the regulations at 42 CFR 483.70(g)(2), SNFs must ensure that services obtained under
an arrangement with an outside source meet professional standards and principles that
apply to professionals providing such services).
However, it is important to note that the absence of a valid arrangement does NOT
invalidate the SNF’s responsibility to reimburse suppliers for services included in the
SNF “bundle” of services represented by the SNF PPS global per diem rate. As the SNF
has already been paid for the services, the SNF must be considered the responsible party
when medically necessary supplier services are furnished to beneficiaries in Medicare
Part A stays. This obligation applies even in cases where the SNF did not specifically
order the service; e.g., during a scheduled physician’s visit, the physician performs
additional diagnostic tests that had not been ordered by the SNF; a family member
arranges a physician visit without the knowledge of SNF staff and the physician bills the
SNF for “incident to” services.
Finally, while establishing a valid arrangement prior to ordering services from a supplier
minimizes the likelihood of a payment dispute between the parties, it is not unreasonable
to expect occasional disagreements between the parties that may result in non-payment of
a supplier claim. However, it is important to note that there are potentially adverse
consequences to SNFs when patterns of such denials are identified. Specifically, all
participating SNFs agree to comply with program regulations when entering into a
Medicare provider agreement which, as explained below, requires a SNF to have a valid
arrangement in place whenever a resident receives services that are subject to
consolidated billing from any entity other than the SNF itself. Moreover, in receiving a

bundled per diem payment under the SNF PPS that includes such services, the SNF is
accepting Medicare payment, and financial responsibility, for the service.
Accordingly, these instructions reiterate and clarify the applicable consolidated billing
requirements that pertain to SNFs and to the outside suppliers that serve SNF residents.
10.4.1 - “Under Arrangements” Relationships
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)
Under an arrangement as defined in §1861(w) of the Act, Medicare’s payment to the SNF
represents payment in full for the arranged-for service, and the supplier must look to the
SNF (rather than to A/B MAC (B)) for its payment. Further, in entering into such an
arrangement, the SNF cannot function as a mere billing conduit, but must actually
exercise professional responsibility over the arranged-for service (see the Medicare
General Information, Eligibility, and Entitlement Manual, Chapter 5, §10.3, and the
Medicare Benefit Policy Manual, Chapter 8, §70.4, for additional information on services
furnished under arrangements).
Medicare does not prescribe the actual terms of the SNF’s relationship with its suppliers
(such as the specific amount or timing of payment by the SNF), which are to be arrived at
through direct negotiation between the parties to the agreement. However, in order for a
valid “arrangement” to exist, the SNF must reach a mutual understanding with its
supplier as to how the supplier is to be paid for its services. Documenting the terms of
the arrangement confers the added benefit of providing both parties with a ready means
of resolution in the event that a dispute arises over a particular service. This type of
arrangement has proven to be effective in situations where suppliers regularly provide
services to facility residents on an ongoing basis; e.g., laboratory and x-ray suppliers,
DME supplies, etc. Sample model agreements involving arrangements between SNFs
and their suppliers are available for review on CMS’s “Best Practices Guidelines”
website, at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/SNFPPS/BestPractices.html.
If a SNF elects to utilize an outside supplier to furnish medically appropriate services that
are subject to consolidated billing, but then refuses to reimburse that supplier for the
services, then there is no valid arrangement as contemplated under §1862(a)(18) of the
Act. Not only would this potentially result in Medicare’s noncoverage of the particular
services at issue, but a SNF demonstrating a pattern of nonpayment would also risk being
found in violation of the terms of its provider agreement. Under §1866(a)(1)(H)(ii) of the
Act (and 42 CFR 489.20(s)), the SNF’s provider agreement includes a specific
commitment to comply with the requirements of the consolidated billing provision.
Further, §1866(g) of the Act imposes a civil money penalty on any person who
knowingly and willfully presents (or causes to be presented) a bill or request for payment
inconsistent with an arrangement or in violation of the requirement for such an
arrangement.

10.4.2 - SNF and Supplier Responsibilities
(Rev. 412, Issued: 12-23-04, Effective: 05-21-04, Implementation: 01-24-05)
Problems involving the absence of a valid arrangement between an SNF and its suppliers
typically tend to arise in one of the following two situations.
Problem Scenario 1: An SNF elects to utilize an outside supplier to furnish a
type of service that would be subject to Part A consolidated billing, but then
fails to inform the supplier that the resident receiving the service is in a
covered Part A stay. This causes the supplier to conclude mistakenly that the
service it furnishes to that resident is not subject to consolidated billing.
Based on the inaccurate impression that the resident’s SNF stay is
noncovered, the supplier inappropriately submits a separate Part B claim for
the service, and may also improperly bill other insurers and the resident.
Then, the supplier only learns of the actual status of the resident’s Medicare-
covered SNF stay when that Part B claim is denied. In this scenario, even
though the supplier made reasonable efforts to ascertain from the SNF both
the beneficiary’s status as an SNF resident and the specific nature of the
beneficiary’s SNF stay, the information from the SNF (on which the supplier
relied) proved to be inaccurate.
While we recognize that inadvertent errors may occasionally occur in the course of
furnishing such information, an SNF should not only make a good faith effort to furnish
accurate information to its supplier, but must reimburse the supplier once such an error is
called to its attention. If, in the scenario at issue, the SNF refuses to pay the supplier for
the service even after being apprised of the inaccuracy of its initial information, the SNF
would not be in compliance with consolidated billing requirements. As discussed
previously, having supporting documentation in place for the disputed service would not
only help to ensure compliance with the consolidated billing requirements, but should
also provide a vehicle for resolving the dispute itself.
Of course, the SNF can often prevent such disputes from arising to begin with, simply by
ensuring that the supplier receives accurate and timely information about the status of a
resident’s Medicare-covered SNF stay. The SNF’s responsibility to communicate
accurate and timely resident information to its suppliers is especially important in those
instances where a particular portion of an otherwise bundled service remains separately
billable to Part B (for example, the professional component that represents a physician’s
interpretation of an otherwise bundled diagnostic test).
Problem Scenario 2: A resident temporarily departs from the SNF on a brief
leave of absence, typically accompanied by a relative or friend. While briefly
offsite, the resident (or the relative or friend, acting on the resident’s behalf)
obtains services that are subject to the consolidated billing requirement, but fails
to notify the SNF. The SNF refuses to pay for the offsite services, and the
supplier bills the beneficiary/family member directly.

As in the previous scenario, the SNF remains responsible for any services included in the
SNF “bundle” of services subject to consolidated billing that are furnished to the resident
by an outside entity, even in the absence of a valid arrangement with the SNF.
The SNFs can act to prevent such problems from arising by ensuring that each resident
(and, if applicable, his or her representative) is fully aware of the applicable
requirements. For example, while the Medicare law at §1802 of the Act guarantees a
beneficiary’s free choice of any qualified entity that is willing to furnish services to the
beneficiary, in selecting a particular SNF, the beneficiary has effectively exercised this
right of free choice with respect to the entire package of services for which the SNF is
responsible under the consolidated billing requirement, including the use of any outside
suppliers from which the SNF chooses to obtain such services. SNF staff need to
communicate these requirements to beneficiaries and family members upon admission.
Further, in providing such advice periodically throughout each resident’s stay, the SNF
should take particular care to include any resident who is about to leave the facility
temporarily, in order to ensure that the resident (and, if applicable, the resident’s
representative) understands the need to consult the SNF before obtaining any services
offsite.
Moreover, while the SNF itself should take reasonable steps to prevent such problems
from arising, the supplier in this scenario is also responsible for being aware of and
complying with the consolidated billing requirements. This means that prior to
furnishing services to a Medicare beneficiary, the supplier should routinely ascertain
whether the beneficiary is currently receiving any comprehensive Medicare benefits
(such as SNF or home health benefits) for which Medicare makes a bundled payment that
could potentially include the supplier’s services. If the supplier ascertains that a
particular beneficiary is, in fact, a resident of an SNF with which the supplier does not
have a valid arrangement in place, then the supplier should contact the SNF before
actually furnishing any services to that beneficiary that are subject to the consolidated
billing provision. Further, under the regulations at 42 CFR 489.21(h), the beneficiary
cannot be charged for the bundled services.
20 - Services Included in Part A PPS Payment Not Billable Separately
by the SNF
(Rev. 2573, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13)
For cost reporting periods beginning on and after July 1, 1998, SNF services paid under
Part A include posthospital SNF services for which benefits are provided under Part A,
and all items and services which, prior to July 1, 1998, had been paid under Part B but
furnished to SNF residents during a Part A covered stay regardless of source, except for
the exclusions listed in the annual SNF consolidated billing update files. Annual update
files, as well as subsequent quarterly updates to the annual update, for SNF consolidated
billing can be found at http://www.cms.hhs.gov/SNFConsolidatedBilling/. This file lists
services by HCPCS code, short descriptors, and the major category under which the
HCPCS falls. HCPCS added or removed by subsequent quarterly update transmittals will
be listed under the respective year’s annual update at the above link. The respective
year’s annual update file will be updated to add or remove the HCPCS listed in the
quarterly updates.

A general explanation of the five major categories can also be found at the above link.
NOTE: It is important for MACs/providers to understand the major categories for SNF
CB. Some major categories exclude services by revenue code (see section 20.1.2.2 for
emergency room exclusion) as well as bill types (see section 20.2.1.2 on coding for renal
dialysis facilities and 20.2.2 for hospice facilities).
Services paid under Part A cannot be billed under Part B. Any service paid under Part A
that is billed separately will not be paid separately, or payment will be recovered if
already paid at the time of the SNF billing. The following subsections list the types of
services that can be billed under Part B for SNF residents for whom Part A payment is
made.
20.1 - Services Beyond the Scope of the Part A SNF Benefit
(Rev. 846, Issued: 02-10-06; Effective: 12-15-05; Implementation: 03-13-06)
The following services are beyond the scope of the SNF Part A benefit and are excluded
from payment under Part A SNF PPS and from the requirement for consolidated billing.
These services must be paid to the practitioner or provider that renders them and are
billed separately by the rendering provider/supplier/practitioner to the A/B MAC (A) or
(B). The SNF may not bill excluded services separately under Part B for its inpatients
entitled to Part A benefits. HCPCS procedure codes representing these excepted services
for services billed to the A/B MACs (A), (B), (HHH), and DME MACs are updated as
frequently as quarterly on the CMS Web site at:
https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/ Physicians, non-
physician practitioners, and suppliers billing the A/B MAC (B) should consult the above
link for lists of separately billable services.
Note: There are separate Annual Update files for service billed to A/B MACs (B)/DME
MACs and services billed to A/B MACs (A) or (HHH) posted to the Web site mentioned
above.
20.1.1 - Physician’s Services and Other Professional Services Excluded
From Part A PPS Payment and the Consolidated Billing Requirement
(Rev. 12283, Issued:10-05-23, Effective:01-08-24, Implementation:01-08-24)
Except for the therapy services (see §20.5), physician’s professional services and
services of certain nonphysician providers listed below are excluded from Part A PPS
payment and the requirement for consolidated billing, and must be billed separately by
the practitioner to the A/B MAC (B). See below for Rural Health Clinic
(RHC)/Federally Qualified Health Center (FQHC) instructions.
For this purpose “physician service” means the professional services of the physician as
defined under the Medicare physician Fee Schedule. For services that contain both a
technical component and a professional component, the technical component, if any,
must be billed by the SNF for its Part A inpatients. The A/B MAC (B) will pay only the

professional component to the physician. For example, the technical component of a
diagnostic radiology test (representing the performance of the procedure itself) is subject
to SNF CB, whereas the professional component (representing the physician’s
interpretation of the test results) is excluded and, thus, remains separately billable under
Part B.
• 	Physician’s services other than physical, occupational, and speech
language pathology services furnished to SNF residents;
• 	Physician assistants, working under a physician’s supervision;
• 	Nurse practitioners and clinical nurse specialists working in collaboration
with a physician;
• 	Certified nurse-midwives;
• 	Qualified psychologists;
• 	Marriage and family therapists;
• 	Mental health counselors; and
• 	Certified registered nurse anesthetists.
SNF CB excludes the categories of practitioner services described above, and this
exclusion applies specifically to those professional services that ordinarily require
performance by the practitioner personally (see the regulations at 42 CFR 411.15(p)(2)(i)
and 415.102(a)(3)). This means, for example, that an otherwise bundled task (such as a
routine blood draw) cannot be converted into an excluded physician service merely by
having a physician perform it personally, as such a task does not ordinarily require
performance by the physician. This exclusion also does not encompass services that are
performed by someone else as an incident to the practitioner’s professional service. Such
“incident to” services remain subject to SNF CB and, accordingly, must be billed to
Medicare by the SNF itself (see §10.3).
Providers with the following specialty codes assigned by CMS upon enrollment with
Medicare are considered physicians for this purpose. Some limitations are imposed by
§§1861(q) and (r) of the Act. These providers may bill their A/B MAC (B) directly.
Physician Specialty Codes
01 General Practice 	02 General Surgery

03 Allergy/Immunology 	04 Otolaryngology
05 Anesthesiology 	06 Cardiology
07 Dermatology 	08 Family Practice
10 Gastroenterology 	11 Internal Medicine
Physician Specialty Codes
12 Osteopathic Manipulative Therapy 	13 Neurology
14 Neurosurgery 	16 Obstetrics Gynecology
18 Ophthalmology 	19 Oral Surgery (Dentists only)
20 Orthopedic Surgery 	22 Pathology
24 Plastic and Reconstructive Surgery 	25 Physical Medicine and Rehabilitation
26 Psychiatry 	28 Colorectal Surgery (formerly Proctology)
29 Pulmonary Disease 	30 Diagnostic Radiology
33 Thoracic Surgery 	34 Urology
35 Chiropractic 	36 Nuclear Medicine
37 Pediatric Medicine 	38 Geriatric Medicine
39 Nephrology 	40 Hand Surgery
41 Optometry 	44 Infectious Disease
46 Endocrinology 	48 Podiatry
66 Rheumatology 	69 Independent Labs
70 Multi specialty Clinic or Group Practice 	76 Peripheral Vascular Disease
77 Vascular Surgery 	78 Cardiac Surgery
79 Addiction Medicine 	81 Critical Care (Intensivists)
82 Hematology 	83 Hematology/Oncology
84 Preventive Medicine 	85 Maxillofacial Surgery
86 Neuropsychiatry 	90 Medical Oncology
91 Surgical Oncology 	92 Radiation Oncology
93 Emergency Medicine 	94 Interventional Radiology
98 Gynecological/Oncology
Nonphysician Provider Specialty Codes
99 Unknown Physician Specialty
42 Certified Nurse Midwife 	43 Certified Registered Nurse Anesthetist,
Anesthesia Assistants (effective 1/1/89)
50 Nurse Practitioner 	62 Clinical Psychologist (billing
independently)
68 Clinical Psychologist 	89 Certified Clinical Nurse Specialist

97 Physician Assistant
NOTE: Some HCPCS codes are defined as all professional components in the fee
schedule. Fee schedule definitions apply for this purpose.
Effective July 1, 2001, the Benefits Improvement and Protection Act (BIPA) established
payment method II, in which CAHs can bill and be paid for physician services billed to
their A/B MAC (A). CAHs must bill the professional fees using revenue codes 96x, 97x,
or 98x on an 85x type of bill (TOB). Like professional services billed to the A/B MAC
(B), the specific line items containing these revenue codes for professional services are
excluded from the requirement for consolidated billing.
RHC/FQHC Instructions:
Effective January 1, 2005, section 410 of the Medicare Prescription Drug, Improvement,
and Modernization Act of 2003 (MMA) amended the SNF consolidated billing law to
specify that when a SNF’s Part A resident receives the services of a physician (or another
type of practitioner that the law identifies as being excluded from SNF consolidated
billing) from a RHC or a FQHC, those services are not subject to CB merely by virtue of
being furnished under the auspices of the RHC or FQHC. Accordingly, under section
410 of the MMA, services otherwise included within the scope of RHC and FQHC
services that are also described in clause (ii) of section 1888(e)(2)(A) are excluded from
consolidated billing, effective with services furnished on or after January 1, 2005. Only
this subset of RHC/FQHC services may be covered and paid separately when furnished
to SNF residents during a covered Part A stay (see the regulations at 42 CFR
411.15(p)(2)(xvii) and 405.2411(b)(2)). Use TOBs 71x and 73x, respectively, to bill for
these RHC/FQHC services. See Pub. 100-02, Medicare Benefit Policy Manual, chapter
13 for additional information on Part B coverage of RHC/FQHC services.
20.1.1.2 - Hospital’s “Facility Charge” in Connection with Clinic
Services of a Physician
(Rev. 3230, Issued: 04-03-15, Effective: 06-15-15, Implementation: 06-15-15)
As noted above in section 20.1.1, physician services are excluded from Part A PPS
payment and the requirement for consolidated billing. When a beneficiary receives clinic
services from a hospital-based physician, the physician in this situation would bill his or
her own professional services directly to the A/B MAC (B) and would be reimbursed at
the facility rate of the Medicare physician fee schedule - which does not include overhead
expenses. The hospital historically has submitted a separate Part B “facility charge” for
the associated overhead expenses to its A/B MAC (A). The hospital’s facility charge
does not involve a separate service (such as a diagnostic test) furnished in addition to the
physician’s professional service; rather, it represents solely the overhead expenses
associated with furnishing the professional service itself. Accordingly, hospitals bill for
“facility charges” under the physician evaluation and management (E&M) codes in the
range of 99201-99245 and G0463 (for hospitals paid under the Outpatient Prospective
Payment System).

E&M codes, representing the hospital’s “facility charge” for the overhead expenses
associated with furnishing the professional service itself, are excluded from SNF CB.
Effective for claims with dates of service on or after January 1, 2006, the CWF will
bypass CB edits when billed with revenue code 0510 (clinic visit) with an E&M HCPCS
code in the range of 99201-99245 and, effective January 1, 2014 with HCPCS code
G0463.
NOTE: Unless otherwise excluded in one of the Five Major Categories for billing
services to A/B MACs (A), physician services codes are to be billed to the A/B MAC (B)
by the physician. Facility charges associated with the physician’s clinic visit must be
reported as explained above.
20.1.2 - Other Excluded Services Beyond the Scope of a SNF Part A
Benefit
(Rev. 4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19)
The following services are not included in Part A PPS payment when furnished in a
Medicare participating hospital or CAH and may be paid to the provider rendering them.
This exception does not apply if the service is furnished in an ambulatory surgical center
(ASC) or other independent (non-hospital) facility, because it specifically addresses those
services that are so far beyond the normal scope of SNF care as to require the intensity of
the hospital setting in order to be furnished safely and effectively. In transmittals for Part
A and B institutional billing providing the annual update list of HCPCS codes affected by
SNF consolidated billing, such services are referred to as “ Major Category I” of SNF
consolidated billing editing. Note that of the types of services listed, only ambulatory
surgeries are listed as inclusions, rather than exclusions, to consolidated billing.
• 	Certain cardiac catheterizations;
• 	Certain computerized axial tomography (CT) scans;
• 	Certain magnetic resonance imaging (MRIs);
• 	Certain ambulatory surgeries involving the use of a hospital operating room or
comparable hospital facilities (i.e., the use of a gastrointestinal (GI) suite or
endoscopy suite for the insertion of a percutaneous esophageal gastrostomy (PEG)
tube). For Part A inpatients, the professional portion of these services is billed by
the rendering practitioner to the A/B MAC (B). Any hospital outpatient charges
are billed to the A/B MAC (A).
• 	Certain radiation therapies;
• 	Certain angiographies, and lymphatic and venous procedures;
• 	Emergency services; and

• 	Ambulance services when related to an excluded service within this list (see §20.3
for ambulance transportation related to dialysis services).
These relatively costly services are beyond the general scope of care in SNFs, and their
receipt has the effect of temporarily suspending a beneficiary’s status as a SNF “resident”
for CB purposes with respect to such services. Even though it may be medically
appropriate for a beneficiary to be cared for in a SNF while receiving radiation therapy,
the SNF is not responsible for paying for excluded radiation therapy itself when the
beneficiary receives it as a hospital outpatient. Similarly, angiography codes and codes
for some lymphatic and venous procedures are considered beyond the general scope of
services delivered by SNFs. The hospital or CAH must bill the A/B MAC (A) for the
services. Excluded services provided to Medicare beneficiaries in swing beds subject to
SNF PPS are to be billed on TOB 13x by the swing bed hospital (see §100.1).
Services directly related to these services, defined as services billed for the same place of
service and with the same line item date of service as the services listed below, are also
excluded from SNF CB, with exceptions as listed below. This language addresses
excluding as “directly related” those items and services that are so closely associated with
the excluded procedure that it would actually be impossible to perform the excluded
procedure itself without them, such as the anesthesia for an excluded ambulatory surgical
procedure under §20.1.2.1, or an otherwise bundled diagnostic test when needed to
identify the cause of (and appropriate course of treatment for) a medical emergency under
§20.1.2.2.
• 	Note that anesthesia, drugs incident to radiology and supplies will be bypassed by
enforcement edits when billed with CT Scans, Cardiac Catheterizations, MRIs,
Radiation Therapies, or Angiographies or surgeries.
In general, bypasses also allow CT Scans, Cardiac Catheterization, MRI, Radiation
Therapy, Angiography, and Outpatient Surgery HCPCS codes 0001T – 0021T, 0024T –
0026T, or 10021 - 69990 (except those HCPCS codes listed in Major Category I. F.) to
process and pay. This includes all other revenue code lines on the incoming claim that
have the same line item date of service (LIDOS).
20.1.2.1 Outpatient Surgery and Related Procedures - INCLUSION
(Rev. 3612, Issued: 09-16-16, Effective: 10-18-16, Implementation: 10-18-16)
Inclusions, rather than exclusions, are given in this one case, because of the great number
of surgical procedures that are excluded and can only be safely performed in a hospital
operating room setting. It is easier to automate edits around the much shorter list of
inclusions under this category, representing minor procedures (such as debriding a
mycotic toenail) that, while technically considered “surgery,” can nevertheless be safely
performed at bedside in the SNF itself. Additionally, this was the approach originally
taken in the regulation to present this information.

• 	Note that anesthesia, drugs, supplies and lab services will be bypassed by
enforcement edits when billed with outpatient surgeries excluded from SNF CB.
The bypass is implemented for these services when the line item date of service
matches the line item date of service for the excluded surgery. For revenue codes
not requiring a line item date of service (i.e., pharmacy and supplies), the bypass
will be implemented when no line item date of service is present.
See §10.1 above for the link to where transmittals providing current lists of HCPCS
codes used for Major Category I SNF consolidated billing editing can be found.
20.1.2.2 - Emergency Services
(Rev. 2573, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13)
Emergency room services performed in hospitals, including CAHs, are excluded from
SNF CB for beneficiaries that are in skilled Part A SNF stays. Hospitals report
emergency room (ER) services under the 045X (Emergency Room -”x” represents a
varying third digit) revenue code with a line item date of service (LIDOS) indicating the
date the patient entered the ER. Services related to the ER encounter are also excluded
from the SNF CB provision. “Emergency” services are defined in the regulations at 42
CFR 424.101 as “. . . services that are necessary to prevent death or serious impairment
of health and, because of the danger to life or health, require use of the most accessible
hospital available and equipped to furnish those services.” In this context, “false alarm”
situations may occasionally arise, in which the initial assessment of a beneficiary’s
condition as life-threatening subsequently proves to be unfounded (for example, where a
patient’s chest pain and shortness of breath initially appear to be symptoms of a heart
attack, but upon subsequent examination turn out to be merely a bad case of indigestion).
Such situations still qualify for the emergency services exclusion from SNF CB as long
as the initial symptoms provided a reasonable basis for assuming the onset of a medical
emergency, even though this assumption ultimately was not borne out by subsequent
events.
Where services related to the ER encounter span more than one service date, hospitals
must identify those services by appending a modifier ET (Emergency Services) to those
line items. The reporting of the ET modifier will alert CWF that these are related ER
services performed on subsequent dates so the SNF CB edits in CWF will be bypassd.
20.2 - Services Excluded from Part A PPS Payment and the
Consolidated Billing Requirement on the Basis of Beneficiary
Characteristics and Election
(Rev. 2573, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13)
SNF-516
These services must be provided to specific beneficiaries, either: (A) End Stage Renal
Disease (ESRD) beneficiaries, or (B) beneficiaries who have elected hospice, by specific
licensed Medicare providers, and are excluded from SNF PPS and consolidated billing.

SNFs will not be paid for Category II.A services (dialysis, etc.) when the SNF is the
place of service. To receive Medicare payment, these services must be provided in a
renal dialysis facility. Hospices must also be the only type of provider billing hospice
services.
In transmittals for A/B MAC (A) billing that provide the annual update list of HCPCS
codes affected by SNF consolidated billing, such services are referred to as “Major
Category II” of SNF consolidated billing editing. See §10.1 above for the link to where
transmittals providing current lists of HCPCS codes used for edits for these types of
services, known as “Major Category II” in SNF CB editing for A/B MACs (A).
20.2.1 – Dialysis and Dialysis Related Services to a Beneficiary With
ESRD
(Rev. 4001, Issued: 03-16-18, Effective: 06-19-18, Implementation: 06-19-18)
Beneficiaries with ESRD may receive dialysis and dialysis related services from a
hospital-based or free-standing RDF, or may receive home dialysis supplies and
equipment from a supplier. The following services are excluded from SNF CB:
• 	Certain dialysis services and supplies, including any related necessary ambulance
services;
• 	Home dialysis supplies and equipment, self-care home dialysis support services,
and institutional dialysis services and supplies (other than those furnished or
arranged for by the SNF itself) are not included in the SNF Part A PPS rate. These
services may be billed separately to the A/B MAC (A) by the ESRD facility as
appropriate; dialysis supplies and equipment may be billed to the Durable
Medical Equipment Medicare Administrative Contractor (DME MAC) by the
supplier; and
• 	Erythropoiesis Stimulating Agents (ESAs) for certain dialysis patients, subject to
methods and standards for its safe and effective use (see 42 CFR 494.80(a)(2) and
(a)(4), 494.90(a)(4), and 494.100) may be billed by the RDF to the A/B MAC
(A), or by the retail pharmacy to the DME MAC.
By contrast, services that fall outside the scope of the Part B dialysis benefit do not
qualify for the dialysis exclusion from SNF CB. Similarly, the SNF CB exclusion
described above for ESAs does not encompass situations involving their use for a non-
dialysis purpose (such as ameliorating the side effects of chemotherapy treatments). The
Part B dialysis benefit generally does not cover dialysis for those beneficiaries who do
not have ESRD. However, an exception involves “acute” dialysis (HCPCS code G0491),
for patients who do not have ESRD but require dialysis temporarily following an acute
kidney injury (AKI) from a severe medical trauma (such as a drug overdose or a traffic
accident). In contrast to maintenance dialysis for ESRD patients (who, in the absence of a
kidney transplant, would remain on periodic dialysis indefinitely), there is an expectation

with acute dialysis that the patient’s own kidneys will eventually recover and resume
their normal function. For services furnished on or after January 1, 2017, section 808(a)
of Public Law 114-27 added acute dialysis to the scope of the Part B dialysis benefit,
thereby effectively adding such services to the scope of the dialysis exclusion from SNF
CB as well.
20.2.1.1 - ESRD Services
(Rev. 1252, Issued: 05-25-07; Effective: 10-01-06; Implementation: 08-27-07)
Home dialysis supplies and equipment, self-care home dialysis support services, and
institutional dialysis services and supplies (other than those that are furnished or arranged
for by the SNF itself) are not included in the Part A PPS payment. They may be billed
separately to the A/B MAC (A) by the hospital or ESRD facility as appropriate.
Specific coding is used to differentiate dialysis and related services that are excluded
from SNF consolidated billing for ESRD beneficiaries in three cases:
1. When the services are provided in a renal dialysis facility (RDF) (including
ambulance services to and from the RDF if medically necessary);
2. Home dialysis when the SNF constitutes the home of the beneficiary; and
3. When ESA drugs are used for ESRD beneficiaries in conjunction with dialysis, and
given by the RDF.
Note that SNFs may not be paid for home dialysis supplies.
20.2.1.2 - Coding Applicable to Dialysis Services Provided in a Renal
Dialysis Facility (RDF) or Home
(Rev. 1252, Issued: 05-25-07; Effective: 10-01-06; Implementation: 08-27-07)
Providers should review Chapter 8, Outpatient ESRD Hospital, Independent Facility, and
Physician/Supplier Claims, for coding applicable to services provided in a Renal Dialysis
Facility.
20.2.2 - Hospice Care for a Beneficiary’s Terminal Illness
(Rev.4163, Issued: 11-02-18, Effective: 12-04-18, Implementation: 12-04-18)
Hospice care related to a beneficiary’s terminal condition is excluded from SNF PPS and
consolidated billing. This is because section 1862(a)(18) of the Social Security Act (the
Act) specifies that SNF consolidated billing applies to “…covered skilled nursing facility
services described in section 1888(e)(2)(A)(i)…” Section 1888(e)(2)(A)(i) of the Act, in
turn, defines “covered skilled nursing facility services” specifically in terms of (I) Part A
SNF services, along with (II) those non-excluded services that (if not for the enactment of
SNF consolidated billing) would be types of services “…for which payment may be
made under Part B…” (emphasis added). Hospice services would not fall within the

scope of clause (I) above because, unlike the diagnostic and therapeutic services
covered under the Part A SNF benefit (see §1862(a)(1)(A) of the Act), hospice services
are palliative (see §1862(a)(1)(C) of the Act). Hospice services also would not fall within
the scope of clause (II) above, because this clause encompasses services that, if not for
the enactment of consolidated billing, would be separately coverable under Part B,
whereas the hospice benefit is a Part A benefit. Hospice services for terminal conditions
are identified with the following types of bill: 81X or 82X. Services unrelated to the
beneficiary’s terminal condition are designated by the presence of condition code 07.
Such unrelated services are included in SNF PPS and consolidated billing.
20.3 - Other Services Excluded from SNF PPS and Consolidated Billing
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)
The following services may be billed separately under Part B by the rendering provider,
supplier, or practitioner (other than the SNF that receives the Part A PPS payment) and
paid to the entity that furnished the service. These services may be provided by any
Medicare provider licensed to provide them, other than the SNF that receives the Part A
PPS payment, and are excluded from Part A PPS payment and the requirement for
consolidated billing, and are referred to as “Major Category III” for consolidated billing
edits applied to claims submitted to A/B MACs (A).
• 	A medically necessary ambulance trip (other than a transfer to another
SNF) that transports a beneficiary to the SNF for the initial admission or
from the SNF following a final discharge, or that occurs pursuant to the
offsite provision of Part B dialysis services (see section 20.3.1 for
additional situations involving ambulance transportation);
• 	Certain chemotherapy (that is, anti-cancer) drugs. The chemotherapy
exclusion applies solely to the particular chemotherapy codes designated
under Major Category III.A of the SNF website’s A/B MAC (A) Annual
Update. These same codes also appear on the list of exclusions in File 1
of the SNF website’s A/B MAC (B) Annual Update (though not displayed
as a separate subcategory). The excluded chemotherapy codes serve to
identify those high-intensity chemotherapy drugs that are not typically
administered in a SNF, are exceptionally expensive, or require special
staff expertise to administer. By contrast, chemotherapy drugs that are
relatively inexpensive and are administered routinely in SNFs do not
qualify for this exclusion and, thus, remain subject to SNF CB. Further,
this exclusion would not encompass any related items that, while
commonly furnished in conjunction with chemotherapy, are not
themselves inherently chemotherapeutic in nature (that is, they specifically
address the side effects of the chemotherapy rather than actively fighting
the cancer itself). Examples of such chemotherapy-related drugs would
include anti-emetics (anti-nausea drugs), as well as drugs that function as
an adjunct to an anti-emetic, such as an anti-anxiety drug that helps to
relieve anticipatory nausea. Even when furnished in conjunction with a
chemotherapy drug that is itself excluded (and, thus, separately payable

under Part B), these related drugs would remain subject to SNF CB.
Similarly, if a drug designated by one of the excluded chemotherapy codes
is prescribed for a use that is not actually associated with fighting cancer,
it would no longer be considered an excluded “chemotherapy” drug in
such an instance, because it is not being used for a chemotherapeutic
purpose within the meaning of this exclusion.
• 	Certain chemotherapy administration services. The chemotherapy
administration codes are included in SNF PPS payment for beneficiaries in
a Part A stay when performed alone or with other surgery, but are
excluded if they occur with the same line item date of service as an
excluded chemotherapy agent. A chemotherapy agent must also be billed
when billing these services, and physician orders must exist to support the
provision of chemotherapy;
• 	Certain radioisotope services;
• 	Certain customized prosthetic devices (see §10);
• 	Effective for items and services furnished on or after October 1, 2021,
certain blood clotting factors indicated for the treatment of hemophilia and
other bleeding disorders;
• 	The transportation costs of electrocardiogram equipment (HCPCS code
R0076), but only with respect to those for electrocardiogram test services
furnished during 1998; and
• 	All services provided to risk-based MCO beneficiaries. These
beneficiaries may be identified with a label attached to their Medicare card
and/or a separate health insurance card from an MCO indicating all
services must be obtained or arranged through the MCO (as noted
previously in §10, consolidated billing applies only to Medicare fee-for-
service beneficiaries).
The HCPCS code ranges for chemotherapy, chemotherapy administration, radioisotopes,
customized prosthetic devices, and blood clotting factors are set in statute. The statute
also gives the Secretary authority to make modifications in the particular codes that are
designated for exclusion within each of these service categories. See §10.1 above for the
link to where transmittals providing current lists of HCPCS codes used for Major
Category III SNF consolidated billing editing for A/B MACs (A) can be found.
20.3.1 - Ambulance Services
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)
The following ambulance transportation and related ambulance services for residents in a
Part A stay are not included in the Part A PPS payment. Except for specific exclusions,

consolidated billing includes those medically necessary ambulance trips that are
furnished during the course of a covered Part A stay. A/B MACs (A), (B), (HHH), and
DME MACs are responsible for assuring that payment is made only for ambulance
services that meet established coverage criteria.
In most cases, ambulance trips are excluded from consolidated billing when resident
status has ended. The ambulance company then must bill the A/B MAC (A), (B), or
(HHH), or DME MAC (as appropriate) directly for payment. Listed below are a number
of specific circumstances under which a beneficiary may receive ambulance services that
are covered by Medicare, but excluded from consolidated billing.
The following ambulance services may be billed as Part B services by the supplier in the
following situations only.
• 	The ambulance trip is to the SNF for admission (the second character
(destination) of any ambulance HCPCS modifier is N (SNF) other than modifier
QN, and the date of service is the same as the SNF 21X admission date.);
• 	The ambulance trip is from the SNF after discharge, to the beneficiary’s home
(the first character (origin) of any HCPCS ambulance modifier is N (SNF), the
second character (destination) of the HCPCS ambulance modifier is R
(Residence), and date of ambulance service is the same date as the SNF through
date). Note: this includes beneficiaries discharged home to receive services from
a Medicare-participating home health agency under a plan of care;
• 	The ambulance trip is to or from a hospital based or nonhospital based ESRD
facility (the first or second character (origin or destination) of the HCPCS
ambulance modifier is N (SNF), and the other character of the HCPCS ambulance
modifier is G (Hospital-based dialysis facility) or J (Non-hospital based dialysis
facility)) for the purpose of receiving dialysis and related services excluded from
consolidated billing.
• 	The ambulance trip is from the SNF to a Medicare-participating hospital or a
CAH for an inpatient admission (the first character (origin) of the HCPCS
ambulance modifier is N (SNF), and the second character (destination) of the
HCPCS modifier is H).
• 	The ambulance trip follows a formal discharge or other departure from the SNF to
any destination other than another SNF, and the beneficiary does not return to that
or any other SNF before the following midnight; and
• 	An ambulance trip that conveys a beneficiary to a hospital or CAH and back to
the SNF, for the specific purpose of receiving emergency or other excluded
services (see section 20.1.2 above for list of other excluded services). As
discussed in section 20.1.2, the receipt of these exceptionally intensive outpatient
hospital services has the effect of temporarily suspending the beneficiary’s status
as an SNF “resident” for CB purposes with respect to those services; moreover,

once suspended in this manner, the beneficiary’s “resident” status would not
resume until he or she actually arrives back at the SNF. Accordingly, the entire
related ambulance roundtrip, both the outbound (SNF-to-hospital) portion and the
return (hospital-to-SNF) portion, would be excluded from SNF CB and billed
separately under Part B.
The following ambulance services are included in SNF CB and may not be billed as Part
B services to the A/B MAC (A), (B), or (HHH) when the beneficiary is in a Part A stay:
• 	Transfers Between Two SNFs: Under the regulations at 42 CFR 411.15(p)(3)(iv),
the day of departure from SNF 1 is a covered Part A day (to which consolidated
billing would apply) only if the beneficiary’s admission to SNF 2 occurs before
the following midnight (the first and second character of the ambulance modifier
is N). Patient Status is 03. An ambulance trip that is medically necessary to
effect this type of SNF-to-SNF transfer would be bundled back to SNF 1, as in
this specific situation the beneficiary would continue to be considered a “resident”
of SNF 1 for CB purposes up until the actual point of admission to SNF 2.
However, it should be noted that in addition to the “medical necessity” criterion in
the regulations at 42 CFR 409.27(c) pertaining specifically to ambulance
transports under the SNF benefit (i.e., the patient’s medical condition is such that
transportation by any means other than ambulance would be contraindicated),
coverage in this context also involves the underlying requirement of being
reasonable and necessary for diagnosing or treating the patient’s condition. For
example, a SNF-to-SNF transfer would be considered reasonable and necessary in
a situation where needed care is unavailable at the originating SNF, thus
necessitating a transfer to the receiving SNF in order to obtain that care. By
contrast, a SNF-to-SNF transfer that is prompted by non-medical considerations
(such as the patient’s preference to be placed in the receiving SNF) is not
considered reasonable and necessary for diagnosing or treating the patient’s
condition and, thus, would not be bundled back to the originating SNF.
• 	Ambulance transports to or from a diagnostic or therapeutic site other than a
hospital or renal dialysis facility (e.g., an independent diagnostic testing facility
(IDTF), cancer treatment center, radiation therapy center, wound care center,
etc.). The ambulance transport is included in the SNF PPS rate if the first or
second character (origin or destination) of any HCPCS code ambulance modifier
is “D” (diagnostic or therapeutic site other than “P” or “H”), and the other
modifier (origin or destination) is “N” (SNF). The first SNF is responsible for
billing the services to the A/B MAC (A).
• 	An SNF resident’s ambulance roundtrip to a physician’s office (first or second
character (origin or destination) of any HCPCS code ambulance modifier is “P”
(physician’s office), and the other modifier (origin or destination) is “N” (SNF))
is subject to SNF CB and would remain the responsibility of the SNF, because
even though the physician’s services are themselves excluded from SNF CB, this
exclusion does not affect the beneficiary’s overall status as an SNF “resident” for
CB purposes. Further, while a physician’s office is not normally a covered

destination under the separate Part B ambulance benefit, the SNF benefit’s Part
A coverage of ambulance transportation under the regulations at 42 CFR
409.27(c) incorporates only the Part B ambulance benefit’s general medical
necessity requirement at 42 CFR 410.40(e)(1), and not any of the latter benefit’s
more detailed coverage restrictions regarding destinations.
See chapter 15 for additional information on Part B coverage of Ambulance Services.
In contrast to the ambulance coverage described above, Medicare simply does not
provide any coverage at all under Part A or Part B for any non-ambulance forms of
transportation, such as ambulette, wheelchair van, or litter van. Further, as noted
previously, in order for the Part A SNF benefit to cover transportation via ambulance, the
regulations at 42 CFR 409.27(c) specify that the ambulance transportation must be
medically necessary, that is, the patient’s condition is such that transportation by any
means other than ambulance would be medically contraindicated.
This means that in a situation where it is medically feasible to transport an SNF resident
by some means other than an ambulance, for example, via wheelchair van, the wheelchair
van would not be covered (because Medicare does not cover any non-ambulance forms of
transportation), and an ambulance also would not be covered (because the use of an
ambulance in such a situation would not be medically necessary). With respect to
noncovered services for which a resident may be financially liable, the SNF is required
under the regulations at 42 CFR 483.10(g)(18) to “. . . inform each resident before, or at
the time of admission, and periodically during the resident’s stay, of services available in
the facility and of charges for those services, including any charges for services not
covered under Medicare/Medicaid or by the facility’s per diem rate.”
20.4 - Screening and Preventive Services
(Rev.4163, Issued: 11-02-18, Effective: 12-04-18, Implementation: 12-04-18)
The Part A SNF benefit is limited to services that are reasonable and necessary to
“diagnose or treat” a condition that has already manifested itself. Accordingly, this
benefit does not encompass screening services (which serve to check an at-risk individual
for the possible presence of a specific latent condition, before it manifests any overt
symptoms to diagnose or treat) or preventive services (which are aimed at warding off the
occurrence of a particular condition altogether rather than diagnosing or treating it once it
occurs). Coverage of screening and preventive services (e.g., screening mammographies,
pneumococcal pneumonia vaccine, influenza vaccine, hepatitis B vaccine) is a separate
Part B inpatient benefit when rendered to beneficiaries in a covered Part A stay and is
paid outside of the Part A payment rate. For this reason, screening and preventive
services must not be included on the global Part A bill. However, screening and
preventive services remain subject to consolidated billing and, thus, must be billed
separately by the SNF under Part B.
Accordingly, even though the SNF itself must bill for these services, it submits a separate
Part B inpatient bill for them rather than including them on its global Part A bill.
Screening and preventive services must be billed with a 22X type of bill. Swing Bed

providers must use TOB 12x for eligible beneficiaries in a Part A SNF level of care.
NOTE: For beneficiaries residing in the Medicare non-certified area of the facility, these
services should be billed on a 23x type of bill. In transmittals for A/B MAC (A) billing
providing the annual update list of HCPCS codes affected by SNF consolidated billing,
such services are referred to as “Major Category IV”. See §10.1 above for the link to
where transmittals providing current lists of HCPCS codes used for Major Category IV
can be found.
There are certain limited circumstances in which a vaccine would no longer be
considered preventive in nature, and this can affect how the vaccine is covered. For
example, while a booster shot of tetanus vaccine would be considered preventive if
administered routinely in accordance with a recommended schedule, it would not be
considered preventive when administered in response to an actual exposure to the disease
(such as an animal bite, or a scratch on a rusty nail). In the latter situation, such a vaccine
furnished to an SNF’s Part A resident would be considered therapeutic rather than
preventive in nature, as its use is reasonable and necessary for treating an existing
condition.
In terms of billing for an SNF’s Part A resident, a vaccine that is administered for
therapeutic rather than preventive purposes would be included on the SNF’s global Part
A bill for the resident’s covered stay. Alternatively, if a vaccine is preventive in nature
and is one of the three types of vaccines (i.e., pneumococcal pneumonia, hepatitis B, or
influenza virus) for which a Part B benefit category exists (see §50.4.4.2 of the Medicare
Benefit Policy Manual, Chapter 15), then the SNF would submit a separate Part B bill for
the vaccine. (Under section 1888(e)(9) of the Social Security Act (the Act) and the
implementing regulations at 42 CFR 413.1(g)(2)(ii), payment for an SNF’s Part B
services generally is made in accordance with the applicable fee schedule for the type of
service being billed (see the Medicare Claims Processing Manual, Chapter 7, §10.5).
However, when these three types of vaccines are furnished in the SNF setting, Part B
makes payment in accordance with the applicable instructions contained in the Medicare
Claims Processing Manual, Chapter 7, §80.1, and Chapter 18, §10.2.2.1.)
If the resident receives a type of vaccine that is preventive in nature but for which no Part
B benefit category exists (e.g., diphtheria), then the vaccine would not be covered under
either Parts A or B and, as a consequence, would become coverable under the Part D drug
benefit. This is because priority of payment between the various parts of the Medicare law
basically proceeds in alphabetical order: Part A is primary to Part B (see section 1833(d) of
the Act), and both Parts A and B are primary to Part D (see section 1860D-2(e)(2)(B) of the
Act).
Further, it is worth noting that unlike preventive services covered under Part B, those
preventive vaccines covered under Part D are not subject to SNF CB, even when
furnished to an SNF’s Part A resident. This is because section 1862(a)(18) of the Act
specifies that SNF CB applies to “. . . covered skilled nursing facility services described
in section 1888(e)(2)(A)(i) . . . .” Section 1888(e)(2)(A)(i) of the Act, in turn, defines
“covered skilled nursing facility services” specifically in terms of (I) Part A SNF
services, along with (II) those non-excluded services that (if not for the enactment of SNF

CB) would be types of services “. . . for which payment may be made under Part B . . .”
(emphasis added). Preventive and screening services as a class would not fall within the
scope of clause (I) above because, as discussed previously, the diagnostic and
therapeutic services covered under the Part A SNF benefit (see §1862(a)(1)(A) of the
Act) do not encompass preventive services (see §1862(a)(1)(B) of the Act) or screening
services (see §§1862(a)(1)(F), (G), (H), (L), (M), and (N) of the Act). Similarly, those
Part D preventive drugs (such as preventive vaccines) for which no Part B benefit
category exists would not fall within the scope of clause (II) above, because this clause
encompasses services that, if not for the enactment of CB, would be separately coverable
under Part B.
Formerly, bone mass measurement (screening) was listed as a preventive service
excluded from SNF consolidated billing. This was incorrect. Such services are
diagnostic, not screening, procedures, and therefore are bundled into SNF PPS payment
and subject to consolidated billing.
20.5 - Therapy Services
(Rev. 2573, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13)
Therapy services are edited as inclusions, rather than exclusions, to consolidated billing.
Physical therapy, speech-language pathology services, and occupational therapy are
bundled into the SNF’s global per diem payment for a resident’s covered Part A stay.
They are also subject to the SNF “Part B” consolidated billing requirement (for services
furnished to SNF residents during noncovered stays) and must be billed by the SNF
alone for its Part B residents on a 22x type of bill.
As noted in section 10.3 of this chapter, therapy services furnished to SNF residents
remain subject to consolidated billing even when performed by a type of practitioner,
such as a physician, whose services would otherwise be excluded (see section
1888(e)(2)(A)(ii) of the Social Security Act and the regulations at 42 CFR
411.15(p)(1)(i)). Further, while most services either clearly fall within the category of
therapy or clearly fall outside of it, there are a few services (such as certain debridement
codes) which, based on the specific type of practitioner involved, are sometimes
considered “therapy” services and other times not. However, because the consolidated
billing provision focuses on the nature of the therapy service itself (rather than the type of
practitioner who happens to be performing it), these “sometimes therapy” codes are
always considered therapy services in the specific context of SNF consolidated
billing. This means that a practitioner who furnishes such a service to an SNF resident
must always look to the SNF itself (rather than to Part B) for payment.
SNF residents that fall below a Medicare skilled level of care may be moved out of the
SNF or certified distinct part unit (DPU) to the Medicare non-certified area of the facility.
In doing so, the beneficiary is no longer subject to the SNF consolidated billing rule and
therapy services may be billed directly to Medicare by the provider rendering the service
or if billed by the SNF should be submitted on a 23x type of bill. If the entire facility
qualifies as a Medicare-certified SNF, all Part B therapies must continue to be billed by
the SNF on a 22x type of bill. The CWF SNF CB therapy edit will be bypassed for 22x

bill types that contain therapy services when those line item dates of service fall within a
non-covered period reported on an inpatient 21x bill type. For additional instructions, see
Chapter 7, SNF Part B Billing, section 10.1. In transmittals for A/B MAC (A) billing
providing the annual update list of HCPCS codes affected by SNF consolidated billing,
such services are referred to as “Major Category V” of SNF consolidated billing. See
section 10.1 above for the link to where transmittals providing current lists of HCPCS
codes used for Major Category V can be found.
20.6 - SNF CB Annual Update Process for A/B MACs (A)
(Rev. 3230, Issued: 04-03-15, Effective: 06-15-15, Implementation: 06-15-15)
Barring any delay in the Medicare Physician Fee Schedule, CMS will provide the new
Annual Update code file to CWF by November 1. Should this date change, CWF will be
notified through the appropriate mechanism. All future updates will be submitted via a
Recurring Update Notification form. These Recurring Update Notifications also describe
how the changes will be implemented.
The CWF contractor shall compare the new code list for Major Categories I through V to
the codes in the current edits. Codes that appear on the new list, but not in the current
edit, shall be added to the edit.
CMS will make a determination as to which codes should be deleted from which edits.
This mechanism will allow for any changes in professional component/technical
component designations to be correctly coded for edits and for deleted codes and codes
no longer valid for Medicare purposes as of the end of the calendar year, to continue to
pay correctly for prior dates of service.
CMS will respond to the list provided by the CWF contractor and provide the
determination on the codes to the CWF contractor.
The CWF contractor will delete codes from the edits per the CMS determination.
A/B MACs (A), a term used to indicate both Part A and Part B institutional services, shall
continue to respond to rejects and unsolicited responses received from CWF per current
methodology. A/B MACs (A) shall reopen and reprocess any claims brought to their
attention for services that prior to this update were mistakenly considered to be subject to
consolidated billing and therefore, not separately payable. A/B MACs (A) need not
search claims history to identify these claims. Prior to January 1 of each year, a new
code file will be posted to the CMS Web site at:
http://www.cms.hhs.gov/SNFConsolidatedBilling/. Should this date change, A/B MACs
(A) will be notified through the appropriate mechanism.
Coding changes throughout the year may also be made as necessary through a quarterly
update process.
As soon as the new code file is posted to the CMS Web site, through their Web sites and
list serves, A/B MACs (A) shall notify providers of the availability of the new file.

30 - Billing SNF PPS Services
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)
SNFs and hospital swing bed providers are required to report inpatient Part A PPS billing
data as follows. Refer to the Medicare Claims Processing Manual, Chapter 25,
“Completing and Processing the Form CMS-1450 Data Set,” for a description of claim
data elements.
• 	In addition to the required fields identified in Chapter 25, SNFs must also report
occurrence span code “70” to indicate the dates of a qualifying hospital stay of at
least three consecutive days which qualifies the beneficiary for SNF services.
• 	Separate bills are required for each Federal fiscal year for admissions that span
the annual update effective date (October 1).
• 	Use Type of Bill 21X for SNF inpatient services or 18X for hospital swing bed
services.
• 	Revenue Code 0022. This code indicates that this claim is being paid under the
SNF PPS. This revenue code can appear on a claim as often as necessary to
indicate different HIPPS Rate Code(s) and assessment periods.
• 	Effective for claims with dates of service on or after January, 1 2011, there must
be an occurrence code 50 (assessment date) for each assessment period
represented on the claim with revenue code 0022. The date of service reported
with occurrence code 50 must contain the ARD. An occurrence code 50 is not
required with default HIPPS code AAAxx (where ‘xx’ equals varying digits) or
ZZZZZ October 1, 2019 and after. In addition, for OMRA related AIs 05, 06, 0A,
0B, 0C, 12, 13, 14, 15, 16, 17, 1A, 1B, 1C, 24, 25, 26, 2A, 2B, 2C, 34, 35, 36, 3A,
3B, 3C, 44, 45, 46, 4A, 4B, 4C, 54, 55, 56, 5A, 5B, 5C where 2 HIPPS may be
produced by one assessment, providers need only report one occurrence code 50
to cover both HIPPS codes. As of October 1, 2019, SNF PDPM changes are
effective (see §§120ff.).
• 	HCPCS/Rates field must contain a 5-digit “HIPPS Code”. The first three
positions of the code contain the RUG group and the last two positions of the
code contain a 2-digit assessment indicator (AI) code. See Chapter 6 of the MDS
RAI manual for valid RUG codes and AI codes. As of October 1, 2019, SNF
PDPM changes are effective (see §§120ff.).
• 	SNF and SB PPS providers must bill the HIPPS codes on the claim form in the
order in which the beneficiary received that level of care.

• 	Service Units must contain the number of covered days for each HIPPS rate code.
NOTE: Fiscal Intermediary Shared System (FISS) requirement:
The sum of all covered units reported on all revenue code 0022 lines
should be equal to the covered days field less the number of days
reported in an OSC 77. (NOTE: The covered units field is utilized in
FISS and has no mapping to the 837 or paper claim).
• 	Total Charges should be zero for revenue code 0022.
• 	When a HIPPS rate code of RUAxx, RUBxx, RUCxx, RULxx and/or RUXxx is
present, a minimum of two rehabilitation therapy ancillary codes are required
(revenue code 042x and/or, 043x and/or, 044x). When a HIPPS rate code of
RHAxx, RHBxx, RHCxx, RHLxx, RHXxx, RLAxx, RLBxx, RLXxx, RMAxx,
RMBxx, RMCxx, RMLxx, RMXxx, RVAxx, RVBxx, RVCxx, RVLxx, and/or
RVXxx is present, a minimum of one rehabilitation therapy ancillary revenue
code is required (revenue code 042x, 043x, or 044x. Bills that are missing
required rehabilitation therapy ancillary revenue codes are to be returned to the
SNF for resubmission. As of October 1, 2019, SNF PDPM changes are effective
(see §§120ff.).
• 	The accommodation revenue code 018x, leave of absence is reported when the
beneficiary is on a leave of absence and is not present at the midnight census
taking time.
• 	Principal Diagnosis Code - SNFs enter the ICD-CM code for the principal
diagnosis in the appropriate form locator. The code must be reported according to
Official ICD-CM Guidelines for Coding and Reporting, as required by the Health
Insurance Portability and Accountability Act (HIPAA), including any applicable
guidelines regarding the use of V codes for ICD-9. The code must be the full
ICD-CM diagnosis code, including all five digits (for ICD-9) or all seven digits
(for ICD-10) where applicable.
• 	Other Diagnosis Codes Required - The SNF enters the full ICD-CM codes
for up to eight additional conditions in the appropriate form locator.
Medicare does not have any additional requirements regarding the
reporting or sequence of the codes beyond those contained in the ICD-CM
guidelines.
30.1 - Health Insurance Prospective Payment System (HIPPS) Rate
Code
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)

The HIPPS rate code consists of the three-character resource utilization group (RUG)
code that is obtained from the “Grouper” software program followed by a 2-digit
assessment indicator (AI) that specifies the type of assessment associated with the RUG
code obtained from the Grouper. Providers may access the Resident Assessment
Instrument (RAI) manual located at the following link for assessment-related issues:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/NursingHomeQualityInits/index.html.
SNFs must use the version of the Grouper software program identified by CMS for
national PPS as described in the Federal Register for that year. The Grouper translates
the data in the Long Term Care Resident Instrument into a case-mix group and assigns
the correct RUG code. Effective for dates of service on or after October 1, 2010, the
Grouper will automatically assign the 2-digit AI.
Providers may access the following link for HIPPS code information:
http://www.cms.hhs.gov/ProspMedicareFeeSvcPmtGen/02_HIPPSCodes.asp#TopOfPage
The above link includes documents that contain the complete list of RUG codes and AIs
billed for Part A SNF stays. Definitions and usage of each code are included. In
addition, a master file of all valid/termed HIPPS codes is provided.
The HIPPS rate code that appears on the claim must match the assessment that has been
transmitted and accepted by the State in which the facility operates. The SNF may bill the
program only after:
• 	An assessment has been completed and submitted to the State RAI Database;
• 	A Final Validation Report indicating that the assessment has been accepted by the
state; and
• 	The covered day has actually been used.
SNFs that submit claims that have not completed this process will not be paid. It is
important to remember that the record will be accepted into the State RAI database, even
if the calculated RUG code differs from the submitted values. The error will be flagged
on the final validation report by issuing a warning message and listing the correct RUG
code. When such discrepancies occur, the RUG code reported on the Final Validation
Report shall be used for billing purposes. As of October 1, 2019, SNF PDPM changes
are effective (see §§120ff.).
30.2 – Coding PPS Bills for Ancillary Services
(Rev. 3230, Issued: 04-03-15, Effective: 06-15-15, Implementation: 06-15-15)
When coding PPS bills for ancillary services associated with a Part A inpatient stay, the
traditional revenue codes will continue to be shown, e.g., 0250 - Pharmacy, 042x -

Physical Therapy, in conjunction with the appropriate entries in Service Units and Total
Charges.
• 	SNFs are required to report the number of units based on the procedure or service.
• 	For therapy services, that is revenue codes 042x, 043x, and 044x, units represent
the number of calendar days of therapy provided. For example, if the beneficiary
received physical therapy, occupational therapy or speech-language pathology on
May 1, that would be considered one calendar day and would be billed as one
unit.
• 	SNFs are required to report the actual charge for each line item, in Total Charges.
30.3 – Adjustment Requests
(Rev. 3230, Issued: 04-03-15, Effective: 06-15-15, Implementation: 06-15-15)
Adjustment requests based on corrected assessments must be submitted within 120 days
of the service “through” date. The “through” date will be used to calculate the period
during which adjustment requests may be submitted based on corrected RAI assessments.
The “through” date indicates the last day of the billing period for which the HIPPS code
is billed. Adjustment requests based on corrected assessments must be submitted within
120 days of the “through” date on the bill. For HIPPS changes resulting from an MDS
correction, providers must append a condition code D2 on their adjustment claim. An
edit is in place to limit the time for submitting this type of adjustment request to 120 days
from the service “through” date.
The CMS expects that most HIPPS code corrections will be made during the course of
the beneficiary’s Medicare Part A stay. Therefore, providers that routinely submit
corrections after the beneficiary’s Part A stay has ended may be subject to focused
medical review.
Adjustment requests to change a HIPPS code may not be submitted for any claim that has
already been medically reviewed, such claims are identified in the FISS system by an
indicator on the claim record. This applies whether or not the medical review was
performed either pre- or post-payment. All adjustment requests submitted are subject to
medical review. Information regarding medical review is located in the Medicare
Program Integrity Manual.
30.4 - SNF PPS Pricer Software
(Rev. 13089; Issued: 02-21-25; Effective: 05-22-25; Implementation: 05-22-25)
The Balanced Budget Act (BBA) of 1997 (Public Law 105-33) mandated the
implementation of a per diem prospective payment system (PPS) for skilled nursing
facilities (SNFs), covering all costs (routine, ancillary, and capital) of covered SNF
services furnished to beneficiaries under Part A of the Medicare program.

Effective for cost reporting periods beginning on or after July 1, 1998, all skilled nursing
services billed on TOB 21x will be paid based on calculations made by the SNF Pricer.
The SNF Pricer operates as a module within CMS’ claims processing systems. The SNF
Pricer makes all payment calculations applicable under SNF PPS.
Medicare claims processing systems maintain a client that communicates with the SNF
Pricer application programming interface (API). The Pricer is made available
electronically to the shared systems and is updated at least annually.
The API describing the elements of SNF PPS claims that are used and the source code
that calculates payments in the SNF Pricer are available to SNFs and their software
vendors at: https://www.cms.gov/pricersourcecodesoftware. This is code is shared
informationally. No part of the SNF Pricer logic is required to be incorporated into a
SNF’s billing system in order to bill Medicare.
A web-based version of the SNF Pricer Program that may be used to estimate SNF PPS
payments can be found at: https://webpricer.cms.gov/ .
Annual Updates to the SNF Pricer
Rate and weight information used by the SNF Pricer is updated periodically, usually
annually. Updates occur each October, to reflect the fact that SNF PPS rates are
effective for a Federal fiscal year. Updates may also occur at other points in the year
when required by legislation.
As of October 1, 2019, SNF PPS payments are made using the Patient-Driven Payment
Model (PDPM). The rate components under the PDPM are described in Section 120.
Whenever these components are updated, Medicare also publishes a Recurring Update
Notification to inform providers and A/B MACs about the changes. These Recurring
Update Notifications also describe how the changes will be implemented through the
SNF Pricer.
30.5 - Annual Updates to the SNF Pricer
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)
Rate and weight information used by the SNF Pricer is updated periodically, usually
annually. Updates occur each October, to reflect the fact that SNF PPS rates are effective
for a Federal fiscal year. Updates may also occur at other points in the year when
required by legislation. The following update items, when changed, are published in the
“Federal Register:"
• 	The following components of the unadjusted Federal rates for both Rural
and Urban areas:
o 	physical therapy,
o 	occupational therapy,
o 	speech-language pathology,
o 	nursing,

o 	non-therapy ancillary, and
o 	non-case-mix.
• 	The case-mix indexes to be used for each case-mix group.
• 	The factors to be applied in making the area wage adjustment.
• 	Changes, if any, to the labor and non-labor percentages.
Whenever these update items change, Medicare also publishes a Recurring Update
Notification to inform providers and A/B MACs (A) about the changes. These Recurring
Update Notifications also describe how the changes will be implemented through the
SNF Pricer.
40 - Special Inpatient Billing Instructions
(Rev. 1733; Issued: 05-08-09; Effective Date: 10-01-06; Implementation Date: 04-
27-09)
The SNFs bill upon the following:
• 	Discharge;
• 	Benefit exhaustion; (Note: Submit both full and partial benefits exhaust claims
monthly)
• 	A decrease in level of care to less than skilled care; or
• 	Monthly (and if necessary, monthly thereafter).
Each bill must include all diagnoses applicable to the admission. However, SNFs do not
include charges that were billed on an earlier bill. The “from” date must be the day after
the “through” date on the prior bill.
40.1 - Submit Bills in Sequence
(Rev. 1, 10-01-03)
SNF-517.13, A3-3603.2
The SNFs must submit bills in sequence for each beneficiary they service. The A/B
MAC (A) will return to the SNF a continuing stay bill if the prior bill has not been
processed. When the A/B MAC (A) receives an out-of-sequence claim for a continuous
stay, it will search its history for the prior adjudicated claim. If the prior bill has not been
finalized, the A/B MAC (A) will return to the provider (RTP), the incoming bill, request
that the prior bill be submitted first, and the returned bill only be submitted after the SNF
receives notice of adjudication of the prior bill. A typical error message follows:
Bills for a continuous stay or admission must be submitted in the same
sequence in which services are furnished. If the provider has not already
done so, please submit the prior bill. Then, resubmit this bill after you
receive the remittance advice for the prior bill.

If the prior bill was submitted, the SNF will hold the returned bill until it receives a
remittance advice for the prior bill.
40.2 - Reprocessing Inpatient Bills in Sequence
(Rev. 2245, Issued: 06-16-11, Effective: 08-01-11, Implementation: 08-01-11)
When a beneficiary experiences multiple admissions (to the same or different facilities)
during a benefit period, claims are processed by CWF in the same order that they are
received, regardless of the dates on which expenses were incurred. This first-in-first-out
method of processing requests for payment facilitates prompt handling of claims.
If a SNF, any beneficiary, or secondary insurer have increased liability as a result of
CWF’s first-in/first-out (FI/FO) processing, the SNF must notify the A/B MAC (A) to
arrange reprocessing of all affected claims. This approach is not applicable if the liability
stays the same, e.g., if the coinsurance or deductible amounts are applied on the second
stay instead of the first, but there is no issue with regard to the effective date of
supplementary coverage or if the beneficiary is responsible for payment of the first claim
instead of the second.
The A/B MAC (A) will verify and cancel any bills posted out-of-sequence and request
that any other A/B MAC (A) involved also cancel any affected bills. The A/B MAC (A)
will reprocess all bills in the benefit period in the sequence of the beneficiary’s stays to
properly allocate days where payment is made in full by Medicare and to identify those
days where the beneficiary is required to pay coinsurance.
40.3 - Determining Part A Admission Date, Discharge Date, and
Utilization Days
(Rev. 1, 10-01-03)
SNF-515.4, SNF-515.4
40.3.1 - Date of Admission
(Rev. 229, Issued 07-20-04 Effective/Implementation 08-19-04)
The beneficiary, entitled to Part A benefits, becomes a SNF resident for Part A PPS
billing purposes when admitted to a Medicare certified SNF or DPU. This could be a
first time admission or a readmission following events described in §40.3.2. Services on
and after this day are included in the PPS rate and cannot be billed by other providers and
suppliers unless excluded as described in this chapter.
40.3.2 - Patient Readmitted Within 30 Days After Discharge
(Rev. 10569, Issued: 01-14-21, Effective: 04-01-21, Implementation: 04-05-21)
A patient is deemed not to have been discharged if the time between SNF discharge and
readmission to the same or another SNF is within 30 days. (See the Medicare Benefit
Policy Manual, Chapter 8, “Coverage of Extended Care Services (SNF) Under Hospital
Insurance,” §20.2.) However, if more than 30 days elapse after the patient’s discharge

from a participating SNF or after his/her transfer to a nonparticipating part of the
institution, the patient must again meet the 3-day hospital stay requirement to become
eligible for SNF benefits. When a discharge bill has been sent and the patient is
readmitted to the SNF within 30 days, the SNF must submit another bill, which shows the
current admission date and the following additional data. • The SNF must complete
condition code “57” on the claim to indicate the patient previously received Medicare
covered SNF care within 30 days of the current SNF admission. • The SNF must
complete occurrence span code “70” to indicate the qualifying stay dates for a hospital
stay of at least 3 days which qualifies the patient for payment of the SNF level of care
services billed on the claim. If a discharge bill has not been sent at the time of
readmission, the SNF must submit an interim bill with occurrence code “74” to show the
from/through dates of the leave of absence (the period the patient was not in the facility)
and the number of noncovered days. For claims that contain both covered days and
noncovered days, and those noncovered days are the responsibility of the beneficiary
(e.g., days submitted for noncovered level of care), the provider should append span code
76 to indicate the days the beneficiary is liable.
40.3.3 - Same Day Transfer
(Rev. 4001, Issued: 03-16-18, Effective: 06-19-18, Implementation: 06-19-18)
The day of admission counts as a utilization day, except in the situation where the patient
was admitted with the expectation that he remain overnight but was transferred to another
participating provider before the following midnight. In this instance, the first provider
completes the bill as follows:
• 	Indicate “0” in Covered Days;
• 	Insert condition code “40” to indicate the patient was transferred from one
participating provider to another before the midnight immediately following the
admission to the first provider; and,
• 	Admission date, statement “from” and “through” dates are the same.
No payment is made to the originating participating provider. Instead, the participating
provider to which the patient was transferred counts the admission day as a utilization
day that includes the day of admission and may bill the HIPPS default code.
If a patient is transferred from a Medicare participating facility to a nonparticipating
facility the day of admission counts as a utilization day and the Medicare-participating
facility may bill the HIPPS default code.

These general rules apply to transfers between SNFs and between a hospital and an SNF.
However, under these same circumstances, if the two providers represent an institution
composed of a participating hospital and a distinct part participating SNF, the first
provider cannot bill for accommodations, but may bill for ancillary charges.
40.3.4 - Situations that Require a Discharge or Leave of Absence
(Rev. 4001, Issued: 03-16-18, Effective: 06-19-18, Implementation: 06-19-18)
Medicare systems are set up so that the SNF need not submit a discharge bill when the
situation is that the beneficiary (who leaves the SNF and then returns before the
following midnight) receives outpatient services from a Medicare participating hospital,
CAH, or other appropriate provider during his/her absence. Edits allow hospitals and
CAHs to bill for these services for a beneficiary in a Part A PPS stay. Receipt of
outpatient services from another provider does not normally result in a SNF discharge.
Two situations force a discharge from a SNF: 1) the beneficiary’s admission as an
inpatient to a Medicare participating hospital or CAH, or 2) the beneficiary’s transfer to
another SNF for inpatient services. A beneficiary cannot be an inpatient in more than one
facility at a time. Consequently, the SNF must submit a discharge bill if either of these
events occur.
If the patient is readmitted to the SNF, the SNF should submit a new bill (TOB 211 or
212) with a new admission date. See §40.3.2, Patient Readmitted Within 30 days After
Discharge, for further instructions.
Bills for excluded services (identified in §20 of this chapter) rendered by participating
hospitals, CAHs, or other appropriate providers may be paid to the rendering provider in
addition to the Part A PPS payment made to the SNF. Other outpatient services furnished
to a resident in a Part A PPS stay by another provider/supplier must be billed by the SNF.
Home health or outpatient services provided during a leave of absence do not affect the
leave and no discharge bill is required.
Home health services are not payable unless the patient is confined to his home, and
under Medicare regulations, a SNF cannot qualify as a home. Where the beneficiary
receives services from a home health agency, the home health agency is responsible for
billing.
If the beneficiary is formally discharged or otherwise departs for reasons other than
described above but then, is readmitted or returns before the following midnight, he is not
considered discharged. The SNF is responsible for billing for services during the period

of absence, unless such services are otherwise excluded from Part A PPS payment or are
excluded from Medicare coverage (see §10.1).
NOTE: This instruction only applies to Medicare fee-for-service beneficiaries in a
participating SNF.
40.3.5 - Determine Utilization on Day of Discharge, Death, or Day
Beginning a Leave of Absence
(Rev. 4001, Issued: 03-16-18, Effective: 06-19-18, Implementation: 06-19-18)
SNF-517.6.B, A3-3103.4
Generally, the day of discharge, death, or a day on which a patient begins a leave of
absence, is not counted as a utilization day. (See the Medicare Benefit Policy Manual,
Chapter 3, “Duration of Covered Inpatient Services.”) This is true even where one of
these events occurs on a patient’s first day of entitlement or the first day of a provider’s
participation in the Medicare program. In addition, a benefit period may begin with a stay
in a hospital or SNF, on that day.
The exception to the general rule of not charging a utilization day for the day of
discharge, death, or day beginning a leave of absence is where the patient is admitted
with the expectation that he will remain overnight but is discharged, dies, or is transferred
to another, nonparticipating provider (or to a nonparticipating portion of the same
provider) before the following midnight. In these instances, such a day counts as a
utilization day. This exception includes the situation where the beneficiary was admitted
(with the expectation that he would remain overnight) on either the first day of his
entitlement or the provider’s first day of participation, and on the same day he was
discharged, died, or transferred to a nonparticipating provider.
Payment is not made under PPS unless a covered day can be billed. Also, for a
noncovered day such as the day of discharge (for which no payment is possible under
PPS), separate billing is not allowed for ancillary services. Ancillary charges for such
days have already been included in the PPS rates for those days that can be billed. This is
because, in accordance with the longstanding instructions in Pub. 15-1, Provider
Reimbursement Manual, Part I, chapter 22, section 2205.1, ancillary charges for services
furnished on the day of (but before the actual moment of) discharge are included on the
SNF’s cost report and reflected in final cost settlement (see also §40.6.3). Accordingly,
such charges have been built into the PPS base. As a result, even though the day of
discharge itself is not a Medicare-covered day for the SNF, the PPS per diem for all of
the covered days leading up to the day of discharge is somewhat higher than it otherwise
would have been, reflecting the historical cost of these day-of-discharge services.
When a patient is discharged on the first day of a provider’s participation or the first day
of the patient’s entitlement, complete the bill as follows:
• Admission date is the actual date of admission;

• From date of service is the date the patient became entitled or date the SNF began
participation; and
• The number of noncovered days = 1.
40.3.5.1 - Day of Discharge or Death Is the Day Following the Close of
the Accounting Year
(Rev. 1, 10-01-03)
SNF-517.2
Where the day of discharge or death is the day following the close of the cost reporting
period, the ancillary charges for services rendered on that day must be included in the bill
submitted for services in the prior accounting year, which includes the covered days for
the billing period in that year. In such cases, “Statement Covers Period”, should show the
date of discharge or death as the through date. The “Patient Status” should reflect the
date of discharge or death, as appropriate. The SNF uses the same billing method when
developing accrued non-Medicare charges. For cost settlement purposes, ancillary
charges incurred in the new fiscal year, but billed under the prior fiscal year, are
considered charges for the prior fiscal year.
40.3.5.2 - Leave of Absence
(Rev. 4001, Issued: 03-16-18, Effective: 06-19-18, Implementation: 06-19-18)
A leave of absence for the purposes of this instruction is a situation where the patient is
absent, but not discharged, for reasons other than admission to a hospital, other SNF, or
nonparticipating portion of the same institution. If the absence exceeds 30 consecutive
days, the 3-day prior stay and 30-day transfer requirements, as appropriate, must again be
met to establish re-entitlement to SNF benefits.
Leave of absence (LOA) days are shown on the bill with revenue code 018X and LOA
days as units. However, charges for LOA days are shown as zero on the bill, and the SNF
cannot bill the beneficiary for them except as specified in Chapter 1 of this manual at
§30.1.1.1. Occurrence span code 74 is used to report the LOA from and through dates.
Providers should review the RAI manual to clarify situations where an LOA is not
appropriate, for example observation stays in a hospital lasting greater than 24 hours.
40.4 - Accommodation Charges Incurred in Different Accounting Years
(Rev. 1, 10-01-03)
SNF-517.1
The SNF must not put accommodation charges incurred in different accounting years on
the same bill. (See §40.3.5.1 when billing for ancillary charges for services furnished on
the day of discharge or death when it is also the day after the end of the accounting year.)
At the end of the accounting year, the SNF must submit a bill that contains the charges

for all services furnished to the patient since the last bill and through the end of that year.
The SNF shows services furnished in the following accounting year on a separate bill.
40.5 - Billing Procedures for Periodic Interim Payment (PIP) Method of
Payment
(Rev. 3220, Issued: 03-16-15, Effective: ICD-10: Upon Implementation of ICD-10,
ASC-X12: 01-01-12, Implementation: 10-01-14, ICD-10: Upon Implementation of
ICD-10 ASC X12: 09-16-14)
The SNFs using the PIP method of payment follow the regular billing instructions in
Medicare Claim Processing Manual, Chapter 25.
See the Medicare Claims Processing Manual, Chapter 1, “General Billing Requirements,”
§80.4, for requirements SNFs must meet and A/B MACs (A) must monitor to continue
PIP reimbursement. Refer to the Medicare Claims Processing Manual, Chapter 25 for
further information about completing the claim.
40.6 - Total and Noncovered Charges
(Rev. 10569, Issued: 01-14-21, Effective: 04-01-21, Implementation: 04-05-21)
ASC X12 837 Institutional Claim See the related implementation guide on the official
Washington Publishing Company website. Form CMS -1450 For each cost center for
which a separate charge is billed (type of accommodation or ancillary), a revenue code is
assigned and is entered on the claim with the related charges. On Form CMS-1450 the
appropriate numeric revenue code is entered in FL 42 to explain each charge in FL 47.
Additionally, there is no fixed “Total” line in the charge area. Instead, revenue code
“0001” is always entered last in FL 42. Thus, the adjacent charge entry, in FL 47, is the
sum of charges billed. This is also the same line on which noncovered charges, if any, in
FL 48, are summed. The total charge for all services, covered and noncovered, will
generally be shown. See §40.6.1 below, for certain exceptions. In the “noncovered
charges” column (FL48) enter the amount of any noncovered charge except where: • The
A/B MAC (A) has notified the SNF that payment can be made under the limitation of
liability provisions; and • A payer primary to Medicare is involved. (See the Medicare
Secondary Payer [MSP] Manual, Chapter 3, “MSP Provider Billing Requirements,” and
Chapter 4, “Contractor Prepayment Processing Requirements.”) Where a bill is submitted
for a period including both covered and noncovered days (e.g., days submitted for
noncovered level of care), the SNF must list the charges for noncovered days under
noncovered charges. Refer to the Medicare Claims Processing Manual, Chapter 25 for
further information about completing the claim. For claims that contain both covered
days and noncovered days, and those noncovered days are the responsibility of the
beneficiary (e.g., days submitted for noncovered level of care), the provider should
append span code 76 to indicate the days the beneficiary is liable.
40.6.1 - Services in Excess of Covered Services

(Rev. 3220, Issued: 03-16-15, Effective: ICD-10: Upon Implementation of ICD-10,
ASC-X12: 01-01-12, Implementation: 10-01-14, ICD-10: Upon Implementation of
ICD-10 ASC X12: 09-16-14)
Where items and services are furnished which are more expensive or in excess of the
services covered by the program, the SNF will make the following entries in the Total
Charges and Noncovered fields on the bill:
• 	If the patient did not request such excess or more expensive services, the patient
may not be charged for them, and only the services covered by the program are
shown in total charges. No entry is made in noncovered charges in this situation.
(However, where all patients are routinely billed for such excess or more
expensive items, total charges may reflect the excess items or services as
discussed in total and noncovered charges, above.);
• 	If the patient did request such excess or more expensive services, the SNF may
charge the patient for them. In this case, the SNF show the line item total charge
(any customary charges covered by the program plus the excess charges). The
excess charges that will be billed to the patient are shown in noncovered charges.
• 	In the same situation as above, except that the SNF will not bill the patient for the
excess services. Instead the SNF will show only the customary charges for
covered services in total charges and make no entry in noncovered charges.
40.6.2 - Showing Discounted Charges
(Rev. 1, 10-01-03)
SNF-517.11
The SNFs do not show credit or minus entries on the bill. Where the SNF gives a
discount to some patients, they show charges in one of two ways:
1. SNFs show the charges as the full, undiscounted charge if full undiscounted charge
data is accumulated for all patients for the purposes of the final cost report; or
2. They show the discounted charges as the only charges, if the SNF, for the purposes
of the final cost report, accumulates charges for all patients at the discounted rate.
40.6.3 - Reporting Accommodations on the Claim
(Rev. 3220, Issued: 03-16-15, Effective: ICD-10: Upon Implementation of ICD-10,
ASC-X12: 01-01-12, Implementation: 10-01-14, ICD-10: Upon Implementation of
ICD-10 ASC X12: 09-16-14)
See the Medicare Benefit Policy Manual, Chapter 1, “Inpatient Hospital Services,” for an
explanation of the rules when other than semi-private accommodations are furnished that
apply to SNFs as well as hospitals. The type of accommodation furnished at the time of
the SNF census-taking hour determines the applicable revenue code. Where a patient is
admitted with the expectation that he will remain overnight, but on the same day is

discharged, dies, or is transferred prior to the census, the revenue code is determined by
the type of accommodation furnished at the time of the patient’s discharge, death, or
transfer.
Payment is based on the PPS rate, not on accommodation levels. See §40.6.1 where the
patient requests more expensive accommodations or patient convenience items.
The determination of charges does not affect the determination of inpatient utilization
days or when a patient may be considered an inpatient for Medicare purposes as outlined
in the Medicare Benefit Policy Manual, Chapter 8, “Coverage of Extended Care (SNF)
Services Under Hospital Insurance,” §50 and §60.2. Refer to the Medicare Claims
Processing Manual, Chapter 25 for further information about billing.
SNFs show total charges for accommodation for the entire billing period and charges for
any noncovered days in noncovered charges.)
The accommodation days do not include the day of death or discharge, even where the
discharge was late. However, where the SNF customarily makes an extra charge for a
late discharge, they include this amount in total charges with the appropriate
accommodation revenue code. The day of discharge is not included in Covered Days
even though an extra charge is included. Where the late discharge was for the patient’s
convenience and not for any medical necessity, SNFs enter the charge for late discharge
as a noncovered charge. Where the late discharge is for a medical reason, the charge is
covered. (See the Medicare Benefit Policy Manual, Chapter 8, “Coverage of Extended
Care (SNF) Services Under Hospital Insurance,” §60.3.)
The charges for accommodations reflect only the total charges for general routine
services as defined in §2202.6 and §2203.1 of the Medicare Provider Reimbursement
Manual. All charges, which are charged to every patient for every patient day, are
included in the routine accommodation charge.
SNFs bill ancillary charges for day of discharge, death or the day on which a leave of
absence begins, under the proper revenue code.
Where the patient is discharged on his first day of entitlement or the first day of the SNF
participation in the Medicare program, they submit a bill with no accommodation charge,
but with ancillary charges.
Where some of the days cannot be paid under Part A because benefits were exhausted
before discharge, death, or the day on which a leave of absence began, SNFs show the
charges for days after benefits where exhausted under noncovered charges, and enter the
appropriate occurrence code, e.g., A3, and the date benefits are exhausted. See the
Medicare Claims Processing Manual, Chapter 7, “SNF Part B Billing,” §10, for billing
under Part B in such circumstances.
40.6.4 - Bills with Covered and Noncovered Days

(Rev. 3220, Issued: 03-16-15, Effective: ICD-10: Upon Implementation of ICD-10,
ASC-X12: 01-01-12, Implementation: 10-01-14, ICD-10: Upon Implementation of
ICD-10 ASC X12: 09-16-14)
Any combination of covered and noncovered days may be billed on the same bill. It is
important to record a day or charge as covered or noncovered because of the following:
• 	Beneficiary utilization is recorded based upon days during which the patient
received hospital or SNF accommodations, including days paid by Medicare and
days for which the provider was held liable for reasons other than medical
necessity or custodial care.
• 	The provider may claim credit on its cost report only for covered
accommodations, days and charges for which actual payment is made. Provider
liable days and charges are not included on the cost report. Data from the bill
payment process are used in preparing the cost report.
SNFs show noncovered charges for denied or noncovered days, which will not be paid.
The SNF submits the bill with occurrence span code 76 and completes the from/through
dates to report periods where the beneficiary is liable. Occurrence span code 77 is used
to report periods of noncovered care where the SNF is liable. If applicable, the FISS
system will automatically assign occurrence code A3 indicating the last date for which
benefits are available or the date benefits were exhausted.
The A/B MAC (A) will use Occurrence Span Code 79 (a payer only code sent to CWF)
to report periods of noncovered care due to lack of medical necessity or custodial care for
which the provider is held liable. Periods of beneficiary liability and provider liability
may be reported on one bill. Report all noncovered days.
See Chapter 25, Completing and Processing the CMS-1450 Data Set, for a complete
description of billing data elements. See the Medicare Claims Processing Manual,
Chapter 30, “Limitation on Liability,” for determining SNF liability.
The provider is always liable unless the appropriate notice is issued. If the SNF issues
the appropriate notice, and the beneficiary agrees to make payment either personally or
through a private insurer, the days will not be charged towards the 100-day benefit
period. Notice requirements for periods of noncoverage are found in Chapter 30, §70.
40.6.5 - Notification of Limitation on Liability Decision
(Rev. 133, 04-02-04)
SNF-517.8
Detailed instructions and application of limitation on liability is found in The Medicare
Claims Processing Manual, Chapter 30, “Limitation on Liability.” The limitation on
liability decision is made by the A/B MAC (A) when the medical evidence and admission
notice, or the bill is submitted. When coverage is denied, notification will be by
telephone, if possible, so written notice can be provided to the patient immediately.

When it is determined during the course of a beneficiary’s stay in an SNF that the care is
not covered but both the beneficiary and the SNF are entitled to limitation on liability, the
Medicare program may make payment for the noncovered services for a grace period of
one day (24 hours) after the date of notice to the SNF or to the beneficiary, whichever is
earlier. If it is determined that more time is required in order to arrange post-discharge
care, up to 1 additional “grace period” day may be paid for.
Limitation of liability may apply to Part A and Part B services furnished by the provider.
40.7 - Ending a Benefit Period
(Rev. 930, Issued: 04-28-06, Effective: 10-01-06, Implementation: 10-02-06)
A benefit period ends 60 days after the beneficiary has ceased to be an inpatient of a
hospital and has not received inpatient skilled care in a SNF during the same 60-day
period.
When the SNF resident's health has improved to the point where he or she no longer
needs or receives the level of skilled care required for Part A coverage, the SNF must bill
one of the two following scenarios:
1. 	For the resident that leaves the Medicare-certified SNF or DPU:
a. 	Submit a final discharge bill, and
b. 	Any services rendered after the discharge and billed by the SNF should be
submitted on a 23x.
2. 	For the resident that remains in the Medicare-certified SNF or DPU after the
skilled level of care has ended:
a. 	Submit the last skilled care claim with an occurrence code 22 to indicate
the date active care ended. i.e., date covered SNF level of care ended, and patient status
code 30 to indicate the patient is still a resident in the Medicare-certified SNF or DPU;
b. 	Any Part B covered services rendered and billed by the SNF after the
skilled care ended should be submitted on a 22x; and
c. 	All therapies must be billed by the SNF on the 22x.
For additional instructions on ending a benefit period go to the Medicare General
Information, Eligibility, and Entitlement Manual, Chapter 3, §10.4.2.
40.8 - Billing in Benefits Exhaust and No-Payment Situations
(Rev. 4491, Issued: 01-09- 20, Effective: 04-01-20, Implementation: 04-06-20)
An SNF is required to submit a bill for a beneficiary that has started a spell of illness
under the SNF Part A benefit for every month of the related stay even though no benefits

may be payable. CMS maintains a record of all inpatient services for each beneficiary,
whether covered or not. The related information is used for national healthcare planning
and also enables CMS to keep track of the beneficiary’s benefit period. These bills have
been required in two situations: 1) when the beneficiary has exhausted his/her 100
covered days under the Medicare SNF benefit (referred to below as benefits exhaust bills)
and 2) when the beneficiary no longer needs a Medicare covered level of care (referred to
below as no-payment bills).
For benefits exhaust bills, an SNF must submit monthly a benefits exhaust bill for those
patients that continue to receive skilled care and also when there is a change in the level
of care regardless of whether the benefits exhaust bill will be paid by Medicaid, a
supplemental insure, or private payer. There are two types of benefits exhaust claims: 1)
Full benefits exhaust claims: no benefit days remain in the beneficiary’s applicable
benefit period for the submitted statement covers from/through date of the claim and 2)
Partial benefits exhaust claims: only one or some benefit days, in the beneficiary’s
applicable benefit period, remain for the submitted statement covers from/through date of
the claim. Monthly claim submission of both types of benefits exhaust bills are required
in order to extend the beneficiary’s applicable benefit period posted in the Common
Working File (CWF). Furthermore, when a change in level of care occurs after
exhaustion of a beneficiary’s covered days of care, the provider must submit the benefits
exhaust bill in the next billing cycle indicating that active care has ended for the
beneficiary.
NOTE: Part B 22x bill types must be submitted after the benefits exhaust claim has been
submitted and processed.
In addition, SNF providers must submit no-payment bills for beneficiaries that have
previously received Medicare-covered skilled care and subsequently dropped to a non-
covered level of care but continue to reside in a Medicare-certified area of the
facility. Consolidated Billing (CB) legislation indicates that physical therapy,
occupational therapy, and speech language pathology services furnished to SNF residents
are always subject to SNF CB. This applies even when a resident receives the therapy
during a non-covered stay in which the beneficiary who is not eligible for Part A
extended care benefit still resides in an institution (or part thereof) that is Medicare-
certified as a SNF. SNF CB edits require the SNF to bill for these services on a 22x
(inpatient part B) bill type. NOTE: Unlike with benefits exhaust claims, Part B 22x bill
types may be submitted prior to the submission of bill type 210 no payment claims.
If a facility has a separate, distinct non-skilled area or wing then beneficiaries may be
discharged to this area using the appropriate patient discharge status code and no-
payment bills would not be required. In addition, SNF CB legislation for therapy
services would not apply for these beneficiaries.
No-payment bills are not required for non-skilled beneficiary admissions. As indicated
above, they are only required for beneficiaries that have previously received covered care
and subsequently dropped to non-covered care and continue to reside in the certified area
of the facility.

NOTE: Providers may bill benefits exhaust and no payment claims using the default
HIPPS code AAA00 prior to October 1, 2019 and ZZZZZ October 1, 2019 and after, in
addition to an appropriate room & board revenue code only. No further ancillary services
need be billed on these claims.
SNF providers and A/B MACs (A) shall follow the billing guidance provided below for
the proper billing of benefits exhaust bills and no-payment bills.
1) 	SNF providers shall submit benefits exhaust claims for those beneficiaries that
continue to receive skilled services as follows:
a) 	Full or partial benefits exhaust claim. (Submitted monthly)
i) 	Bill Type = Use appropriate covered bill type (i.e., 211, 212, 213 or 214 for
SNF and 181, 182, 183 or 184 for Swing Bed (SB). NOTE: Bill types 210 or
180 should not be used for benefits exhaust claims submission).
ii) Occurrence Span Code 70 with the qualifying hospital stay dates.
iii) Covered Days and Charges = Submit all covered days and charges as if
beneficiary had days available.
iv) Value Code 09 (First year coinsurance amount) 1.00 (If applicable, the FISS
will assign the correct coinsurance amount based off the CWF response).
v) 	Patient Status Code = Use appropriate code.
b) 	Benefits exhaust claim with a drop in level of care within the month; Patient
remains in the Medicare-certified area of the facility after the drop in level of
care.
i) 	Bill Type = Use appropriate bill type (i.e., 212 or 213 for SNF and 182 or 183
for SB. NOTE: Bill types 210 or 180 should not be used for benefits exhaust
claims submission).
ii) Occurrence Span Code 70 with the qualifying hospital stay dates.
iii) Occurrence Code 22 (date active care ended, i.e., date covered SNF level of
care ended) = include the date active care ended; this should match the
statement covers through date on the claim.
iv) Covered Days and Charges = Submit all covered days and charges as if the
beneficiary had days available up until the date active care ended.

v) 	Value Code 09 (First year coinsurance amount) 1.00 (If applicable, the FISS
will assign the correct coinsurance amount based off the CWF response).
vi) Patient Status Code = 30 (still patient).
c) 	Benefits exhaust claim with a patient discharge.
i) 	Bill Type = 211 or 214 for SNF and 181 or 184 for SB (NOTE: Bill types 210
or 180 should not be used for benefits exhaust claims submission).
ii) Covered Days and Charges = Submit all covered days and charges as if
beneficiary had days available up until the date active care ended.
iii) Value Code 09 (First year coinsurance amount) 1.00 (If applicable, the FISS
will assign the correct coinsurance amount based off the CWF response).
iv) Patient Status Code = Use appropriate code other than patient status code 30
(still patient).
NOTE: Billing all covered days and charges allow the Common Working File (CWF) to
assign the correct benefits exhaust denial to the claim and appropriately post the claim to
the patient’s benefit period. Benefits exhaust bills must be submitted monthly.
2) 	SNF providers shall submit no-payment claims for beneficiaries that previously
dropped to non-skilled care and continue to reside in the Medicare-certified area of
the facility using the following options.
a) 	Patient previously dropped to non-skilled care. Provider needs Medicare
denial notice for other insurers.
i) 	Bill Type = 210 (SNF no-payment bill type) or 180 (SB no-payment bill type)
ii) Statement Covers From and Through Dates = days provider is billing, which
may be submitted as frequently as monthly, in order to receive a denial for
other insurer purposes. No-payment billing shall start the day following the
date active care ended.
iii) Days and Charges = Non-covered days and charges beginning with the day
after active care ended.
iv) Condition Code 21 (billing for denial).
v) 	Patient Status Code = Use appropriate code.

b) 	Patient previously dropped to non-skilled care. In these cases, the provider
must only submit the final discharge bill that may span multiple months but
must be as often as necessary to meet timely filing guidelines.
i) 	Bill Type = 210 (SNF no-payment bill type) or 180 (SB no-payment bill type)
ii) Statement Covers From and Through Dates = days billed by the provider,
which may span multiple months, in order to show final discharge of the
patient. No-payment billing shall start the day following the date active care
ended.
iii) Days and Charges = Non-covered days and charges beginning with the day
after active care ended.
iv) Condition Code 21 (billing for denial).
v) 	Patient Status Code = Use appropriate code other than patient status code 30
(still patient).
NOTE: No pay bills may span both provider and Medicare fiscal year end dates.
Refer to Chapter 25 for further information about billing.

40.8.1 – SNF Spell of Illness Quick Reference Chart
(Rev.4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19)
Level of
Care
Patient's
Medicare
SNF Part A
Benefits Are
Exhausted
Patient Is
In
Medicare
Certified
Area of
the
Facility *
If in non-
Medicare
Area, the
Facility Meets
the Definition
of a SNF **
Is the
Inpatient
Spell of
Illness
Continued?
Billing Action
Medicare
Skilled
YES 	YES 	N/A 	YES 	Submit Monthly Covered Claim.
NO 	YES 	N/A 	YES 	Submit Monthly Covered Claim.
YES 	NO 	YES 	YES 	Submit Monthly Covered Claim.
NO 	NO 	YES 	YES
Patient should be returned to certified area for Medicare to be
billed. Submit Monthly Covered Claim.
NO 	NO 	NO 	NO
Facility should determine whether it would be
appropriate to send patient back to a certified area for
Medicare coverage.
Not
Medicare
Skilled YES 	NO 	NO 	NO
Do not submit claim if pt came in non-skilled. Otherwise,
submit no-pay claim w/ discharge status code when patient
leaves the certified area.

YES 	YES 	N/A 	NO
Do not submit claim if pt came in non-skilled. Otherwise,
submit no-pay claim w/ discharge status code when patient
leaves the certified area.
NO 	YES 	N/A 	NO
Do not submit claim if pt came in non-skilled. Otherwise,
submit no-pay claim w/ discharge status code when patient leaves the
certified area.
NO 	NO 	YES 	NO
Do not submit claim if pt came in non-skilled. Otherwise,
submit no-pay claim w/ discharge status code when patient
leaves the certified area.
YES 	NO 	YES 	NO
Do not submit claim if pt came in non-skilled. Otherwise,
submit no-pay claim w/ discharge status code when patient
leaves the certified area.
* Whether the facility considers a patient's bed in the certified area to be a Medicare bed or not has no effect on whether the spell of
illness is continued and has no effect on the SNF's action.
** In some states, licensing laws for all nursing homes have incorporated requirements of the basic SNF definition (Social Security
Act §1819(a)(1)). When this is the case, any nursing home in such a state would be considered to meet this definition (see CMS
Internet-Only Manual, Pub. 100-7, Chapter 2, §2164 at www.cms.hhs.gov/manuals/ on the CMS website).

40.8.2 - Billing When Qualifying Stay or Transfer Criteria are Not Met
(Rev. 1618, Issued: 10-24-08, Effective: 04-01-09; Implementation: 04-06-09)
SNF providers are required to submit claims to Medicare for beneficiaries that receive a
skilled level of care. This includes beneficiaries that do not meet the qualifying stay or
transfer criteria. Although these claims will not be paid by Medicare, providers must
submit these claims as covered in order to extend existing beneficiary spells of illness in
CWF. A prior qualifying hospital stay (occurrence span code 70) would not be
applicable and shall not be included with these claims. This will allow Medicare systems
to deny the claim for the appropriate reason.
Note: This instruction includes beneficiaries that were previously admitted for skilled
care then subsequently drop to non-skilled for greater than 30 days and then require
skilled care again but do not have a new qualifying hospital stay.
40.9 - Other Billing Situations
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)
A. Demand Bills
Where the SNF believes that a covered level of care has ended but the beneficiary
disagrees, they report occurrence code 21 (UR notice received) or 22 (date active care
ended) as applicable and condition code 20 indicating the beneficiary believes the
services are covered beyond the occurrence date.
See the Medicare Claims Processing Manual, Chapter 1, “General Billing Requirements,”
§60.3, for instructions on advance beneficiary notices and demand bills.
Refer to the Medicare Claims Processing Manual, Chapter 25 for further information
about billing.
B. Request for Denial Notice for Other Insurer
The SNFs complete a noncovered bill and enter condition code 21 to indicate a request
for a Medicare denial notice. Refer to Chapter 25 further information about billing.
C. Another Insurer is Primary to Medicare
See the Medicare Secondary Payer (MSP) Manual, Chapter 3, “MSP Provider Billing
Requirements” and Chapter 5, “Contractor Prepayment Processing Requirements,” for
submitting claims for secondary benefits to Medicare. Refer to the Medicare Claims
Processing Manual, Chapter 25 for further information about billing.
D. Special MSN Messages
The Medicare Prescription Drug Improvement and Modernization Act of 2003 requires
that Medicare Summary Notices (including SNF claims for post-hospital extended care

services provided under Part A) report the number of covered days remaining in the given
spell of illness. This requirement became effective July 6, 2004.
E. Interrupted Stay
Refer to the Medicare Claims Processing Manual, Chapter 6, “Interrupted Stay Policy,”
§120.2, for information about billing when a patient returns to a covered level of care
after an interrupted stay.
50 - SNF Payment Bans, or Denial of Payment for New Admissions
(DPNA)
(Rev. 1555; Issued: 07-18-08; Effective Date: 01-01-09; Implementation Date: 01-
05-09)
Under the Act at §§1819(h) and 1919(h) and CMS’ regulations at 42 CFR 488.417, CMS
may impose a denial of payment for new admissions (DPNA) against a SNF when a
facility is not in substantial compliance with requirements of participation. To understand
the effect on coverage of SNF services, see the Medicare Benefit Policy Manual, Chapter
8, “Coverage of Extended Care (SNF) Services Under Hospital Insurance,” §§20.3 -
20.3.1.6.
50.1 - Effect on Utilization Days and Benefit Period
(Rev. 1555; Issued: 07-18-08; Effective Date: 01-01-09; Implementation Date: 01-
05-09)
Payment sanctions are applied to days that would otherwise be Part A-payable; i.e., the
care is covered but no payment will be made to the provider. Therefore, if the Medicare
participating SNF assumes responsibility for the beneficiary’s costs during the sanction
period, it will be considered the same as a program payment, and the days will count
towards the 100-day benefit period.
In situations where the beneficiary is subject to the payment ban, but the provider fails to
issue the proper beneficiary liability notice, the provider is liable for all services normally
covered under the Medicare Part A benefit. Since the beneficiary is receiving benefits,
the days will be considered Part A days and charged against the beneficiary’s benefit
period. The SNF may collect any applicable copayment amounts. These days will be
charged against the beneficiary’s utilization as is currently done with other types of
technical denials (i.e., late filing, late denial notices to the patient, etc.).
If the SNF issues the appropriate beneficiary liability notice, and the beneficiary agrees to
make payment either personally or through a private insurer, the days will not be charged
towards the 100-day benefit period.
50.2 - Billing When Ban on Payment Is In Effect

(Rev. 1555; Issued: 07-18-08; Effective Date: 01-01-09; Implementation Date: 01-
05-09)
Beneficiaries admitted before the effective date of the denial of payment and taking
temporary leave, whether to receive inpatient hospital care, outpatient services or as
therapeutic leave, are not considered new admissions, and are not subject to the denial of
payment upon return. This policy applies even if there are multiple hospitalizations and
returns to the SNF during the period sanctions are in effect.
When determining if the beneficiary was admitted prior to the imposition of the ban, the
actual status of the beneficiary rather than the primary payor is the determining factor.
Therefore, there may be situations where the beneficiary is a private pay patient or a dual
eligible who was receiving Medicaid benefits prior to the imposition of the payment ban.
If this private pay patient or dual eligible goes to the hospital for needed care, and meets
the Medicare Part A criteria for SNF coverage upon return to the SNF, the readmission is
exempt from the denial of payment sanction. When billing for a readmission that is NOT
subject to the payment ban, providers must enter occurrence span code 80, Prior Same-
SNF Stay Dates for Payment Ban Purposes, on the claim to identify the prior same-SNF
stay dates, in addition to reporting any LOA and prior hospital stay dates, using
occurrence span codes, that may affect the A/B MACs (A)’s determination of payment
ban exemption status. See Chapter 25 of this manual for occurrence span code titles and
definitions.
50.2.1 - Effect of an Appeal to a DPNA on Billing During the Period the
SNF is Subject to a DPNA
(Rev. 1555; Issued: 07-18-08; Effective Date: 01-01-09; Implementation Date: 01-
05-09)
In those situations where the SNF decides to appeal the imposition of a DPNA, it must
still bill the program as set forth in the instructions below.
50.2.2 - Provider Liability Billing Instructions
(Rev. 1555; Issued: 07-18-08; Effective Date: 01-01-09; Implementation Date: 01-
05-09)
The SNF must file a covered bill with the A/B MAC (A) using occurrence span code 77
that indicates the facility is liable for the services in situations where the SNF failed to
issue the proper beneficiary liability notice and any applicable copayments will be
charged to the beneficiary’s Part A benefit period. Furthermore, the sum of all covered
units reported on all revenue code 0022 lines should be equal to the covered days field
less the number of provider liable days reported in the occurrence span code 77. See §60
of Chapter 1 in this manual for detailed instructions on nonpayment billing requirements.
When the SNF is liable for the Part A stay, the SNF is required to provide all necessary
covered Part A services, including those services such as therapies and radiology
mandated under consolidated billing. For example, if the beneficiary goes to the hospital

for a non-emergency chest x-ray, the SNF will be responsible for the outpatient hospital
radiology and any ambulance charges. In this case, the SNF may not charge the
beneficiary or family members for any services that, in the absence of a payment
sanction, would have been covered under the Part A PPS payment.
50.2.3 - Beneficiary Liability Billing Instructions
(Rev. 1555; Issued: 07-18-08; Effective Date: 01-01-09; Implementation Date: 01-
05-09)
The SNF shall file a non-payment bill for noncovered Part A services, using condition
code 21 that indicates beneficiary liability. Services that would have been eligible for
Part A benefits in the absence of sanctions cannot be billed as Part B charges. However,
the SNF may directly bill the beneficiary, family members or other third party insurers
for services provided to that beneficiary.
50.2.4 - Part B Billing
(Rev. 1, 10-01-03)
PM AB-01-131
Facilities subject to a payment ban may continue to bill services for beneficiaries who are
not in a Part A stay in the same way as any other SNF. However, services that would
have been payable to the SNF as Part A benefits in the absence of a payment sanction
must not be billed to either the A/B MAC (A) or the A/B MAC (B) as Part B services.
50.3 - Sanctions Lifted: Procedures for Beneficiaries Admitted During
the Sanction Period
(Rev. 1, 10-01-03)
PM AB-01-131
For new admissions to certified beds, Medicare payments for eligible beneficiaries should
begin on the date the sanction is lifted. The beneficiary must meet technical eligibility
requirements (e.g., a 3-day hospital stay, etc.), services must be reasonable and necessary
and the beneficiary must be receiving skilled care. The date the sanction is lifted is
considered the first day of the Part A stay.
For Part A PPS payment purposes, the period between the actual date of admission and
the last day the sanction was in effect should be billed as noncovered days.
(See §50.3.1 below on procedures to track these noncovered days for benefit period and
break in spell of illness calculations. RAI requirements are discussed in §30.5.)
50.3.1 - Tracking the Benefit Period
(Rev. 1555; Issued: 07-18-08; Effective Date: 01-01-09; Implementation Date: 01-
05-09)

SNF days during the sanction period will be used to track breaks in the spell of illness if a
beneficiary’s care in the SNF meets the skilled level of care requirements. If the patient
is receiving a skilled level of care the benefit period cannot end. Therefore, it will be
tracked in CWF.
50.3.2 - Determining Whether Transfer Requirements Have Been Met
(Rev. 1, 10-01-03)
PM AB-01-131
It is very important to safeguard the beneficiary while applying necessary sanctions to the
provider. It is certainly possible that a beneficiary may remain at a facility under sanction
for a period of time and later transfer to a second SNF. The 30-day transfer requirement
will be applied in the same way it would be for a beneficiary transferring between two
SNFs that are not under sanction. Part A coverage will be available to the second SNF
for all remaining days in the benefit period as long as the beneficiary:
1. Had a qualifying hospital stay
2. Was admitted to a Medicare-certified bed in the first (sanctioned) SNF within 30
days of the hospital discharge, and
3. Is receiving a covered level of care at the time of transfer.
50.4 - Conducting Resident Assessments
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)
The imposition of sanctions does not waive the SNF’s responsibility to perform
assessments in accordance with the clinical schedule defined in the SOM.
Comprehensive admission assessments are still due within 14 days of admission to the
SNF. Facility staff must also maintain the schedule for quarterly and annual assessments,
and perform SCSAs and SCPAs when clinically appropriate.
Medicare-required assessments are also necessary for all beneficiaries in the SNF whose
stays are not subject to the payment ban. If, during the sanction period, staff do not
perform Medicare-required assessments for beneficiaries in covered Part A stays, no
payment is made and the SNF must submit a claim using the HIPPS default rate code and
an occurrence code 77 indicating provider liability, in order to ensure that the
beneficiary’s spell of illness (benefit period) is updated.
Part A benefits are NOT available for beneficiaries admitted after the effective date of the
payment ban. Therefore, the facility is not required to perform Medicare PPS
assessments. Medicare payments can begin no earlier than the date the sanction is lifted.
For Medicare PPS assessment scheduling purposes, the date the sanction is lifted should
be considered day 1. In this case, if the sanctions are lifted effective June 15, the

assessment reference date for the Medicare 5-day assessment must be set between June
15 and June 22 (i.e., the eighth day of the covered stay).
An SNF may choose to perform the Medicare-required assessments during the sanction
period, but is not required to do so. Generally, a facility should continue to do the
Medicare PPS assessments if SNF staff believe the sanction was in error and may be
lifted retroactively. In this case, the SNF would be able to bill Medicare at the correct
rate.
When the SNF does not receive timely notification that a payment ban has been lifted,
and staff is unaware of the need to start the Medicare-Required schedule (the beneficiary
meets all applicable eligibility and coverage requirements), the SNF shall bill the
Medicare 5-day and 14-day assessment using the HIPPS code generated by the 14-day
OBRA required assessment. If the SNF did not perform any assessments with an
assessment reference date during the assessment window for the Medicare-Required 5-
day or 14-day assessment, the SNF shall bill the default rate for those covered days
associated with the assessment. Where the SNF did not perform an assessment with an
ARD that fell in the applicable Medicare-Required Assessment window for the 30, 60
and 90-day Medicare-Required Assessments it shall bill the default rate. If the SNF did
perform an assessment, including a SCSA, where the ARD fell in the window of a 30, 60
or 90-day Medicare-Required Assessment (including grace days), the SNF shall bill using
the HIPPS code generated from the assessment in accordance with the payment policies
found in Chapter 28 of the Provider Reimbursement Manual. The date the sanction is
lifted is Day 1 for purposes of the Medicare assessment schedule.
NOTE: In order to bill with the default code the beneficiary must at least meet the
requirements for SNF coverage.
EXAMPLE 1: 	The SNF is notified on June 15th that its payment ban was lifted
effective June 1. The beneficiary was admitted on June 1. The SNF
did not perform any of the Medicare-Required Assessments.
However, the SNF did perform the initial OBRA assessment. The
initial OBRA assessment shall be used to bill the 5-day Medicare-
Required Assessment for up to 14 days. Day 15 is day 1 for purposes
of starting the Medicare-required assessment schedule and a 5-day
Medicare required assessment shall be performed.
EXAMPLE 2: 	The SNF is notified on August 15 that its payment ban was lifted on
June 1. The beneficiary was admitted on June 1. The SNF did not
perform any of the Medicare-Required Assessments. However, the
SNF did perform the initial OBRA Assessment. The initial OBRA
assessment shall be used to bill the 5-day Medicare required
assessment and the 14-day Medicare required assessment. The 30-day
assessment shall be billed through day 44 at the default rate. Day 45 is
day 1 for purposes of starting the Medicare- required assessment
schedule and a 5-day Medicare required assessment shall be
performed.

See §120.1 for the revised Medicare-required assessment schedule under the SNF PDPM
effective October 1, 2019.
50.5 - Physician Certification
(Rev. 1, 10-01-03)
PM AB-01-131
The SNFs under a payment ban are still participating providers, and remain subject to
Medicare coverage requirements. Providers are still responsible for evaluating whether
beneficiaries meet the Medicare Part A medical necessity and level of care requirements
for Medicare Part A coverage, and for obtaining the required physician certifications
even though Medicare payment cannot be made for the admission.
The SNFs are required to obtain physician certifications upon notification that a sanction
was lifted. The date of notification will be considered day 1 when verifying the
timeliness of the physician certification.
When A/B MACs (A) process a reconsideration for a claim that was billed as a Part A
stay, but rejected due to an incorrect application of the sanction provision, the physician
certification is required regardless of the dates of service. Since the provider clearly
believed the stay was eligible for Part A payment, all Medicare coverage requirements
must have been met.
50.6 - A/B MACs (A) Responsibilities
(Rev. 1555; Issued: 07-18-08; Effective Date: 01-01-09; Implementation Date: 01-
05-09)
The A/B MACs (A) will receive notices from the CMS Regional Office when sanctions
have been imposed or lifted and in some cases when sanctions are proposed. The CMS’
primary objective is always to bring the facility into compliance. In many cases,
enforcement activity does not go beyond the notice of intent. A/B MACs (A) shall
initiate action only when notified that sanctions have been imposed.
Upon notification that a sanction is imposed, A/B MACs (A) shall identify claims
affected with admission dates on and after the effective date of the sanction.
Overpayments for claims erroneously paid should be recovered and CWF properly
updated to reflect the payment ban action. Claims for new admissions should be denied
from the date of admission through the last date of the sanction period.
In addition, A/B MACs (A) shall determine whether claims with admission dates after the
effective date of the sanctions qualify for readmission status, as defined in the previous
sections, and are not subject to a payment ban. A/B MACs (A) shall bypass local
payment ban edits for claims that are not subject to a payment ban when dates associated
with occurrence span code 80, Prior Same-SNF stay for payment ban purposes, indicates

the beneficiary resided in the SNF prior to the imposition of the ban. (See §50.2 above
for further payment ban bypassing criteria for hospitalizations and LOAs).
50.7 - Retroactive Removal of Sanctions
(Rev. 4409, Issued: 10-04- 19, Effective: 11-05-19, Implementation: 11-05-19)
PM AB-01-131
Occasionally, resolution between the State Agency and the SNF is reached after the
payment ban has been imposed, and the ban is removed retroactive to its effective
date. If bills were denied before notice was received that the ban had been reversed, they
should be reprocessed and paid. When reprocessing bills, MDS assessments are needed
to support the case-mix classification group billed.
Beneficiaries and providers may request A/B MACs (A) to reopen and process bills
denied as a result of a misunderstanding of the sanction requirements. These reopenings
shall be done on a request basis only, and will be limited to service dates on and after
January 1, 1999.
60 - Billing Procedures for a Composite SNF or a Change in Provider
Number
(Rev. 767, Issued: 12-02-05, Effective: N/A, Implementation: N/A)
SNF-520, A3-3600.5
A hospital with a sub-provider that meets the criteria for a composite distinct part SNF
defined in 42 CFR 483.5 is required to use the single SNF number assigned for all claims,
beginning with the date the provider number is effective.
Where there is a change of ownership (CHOW), and the new owner refuses assignment
of the existing provider agreement, the old owner submits all claims for periods prior to
the CHOW using the old provider number. The new owner submits claims for services
rendered after the date of the CHOW using the new provider number.
Also with respect to CHOWs, the SNF submits a bill with the old provider number for
the period before the change and another with the new provider number for the period
after the change. The date of discharge on the first bill and the date of admission on the
second bill are the same, which is the effective date of the new provider number. All
subsequent billings are submitted under the new provider number.
70 - Billing for Services After Termination of Provider Agreement, or
After Payment is Denied for New Admissions
(Rev. 767, Issued: 12-02-05, Effective: N/A, Implementation: N/A)
70.1 - General Rules
(Rev. 767, Issued: 12-02-05, Effective: N/A, Implementation: N/A)

A SNF whose provider agreement terminates or that is denied payment for new
admissions as an alternative to termination for noncompliance with one or more
requirements for participation, may only be paid for covered Part A inpatient services
under the following conditions:
Termination (Voluntary or Involuntary)
• 	Payment can continue to be made for up to 30 days for covered Part A inpatient
services furnished on and after the effective date of termination for beneficiaries
who were admitted prior to the termination date.
EXAMPLE: 	Termination date: 9/30/86
o 	Beneficiary admitted: before 9/30/86
o 	Payment can be made: from 9/30/86, up to and including 10/29/86
Denial of Payments for New Admissions (DPNA)
• 	Payment can continue to be made for covered Part A inpatient services furnished
on or after the effective date of denial of payments for beneficiaries who were
admitted before the effective date of denial of payments.
EXAMPLE: 	Denial of payment date: 9/30/86
o 	Beneficiary admitted before: 9/30/86
o 	Payment can be made: Indefinitely
For detailed instructions on SNF payment bans, or denial of payment for new admission
see IOM 100-04, Chapter 6, section 50.
NOTE: An inpatient, who goes on leave from the SNF before or after the effective date
of denial of payments for new admissions is not considered a new admission when
returning from leave.
70.2 - Billing for Covered Services
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary’s Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
Upon cessation of a SNF’s participation in the program, or when a SNF is not receiving
payments for new admissions, the RO is supplied with the names and Medicare

beneficiary identifiers of Medicare beneficiaries entitled to have payment made on their
behalf for services in accordance with §80.1.
SNFs no longer participating in the program, or those under a denial of payment for new
admissions, continue to bill for covered services per §80.l. They continue to submit “no-
payment” death, discharge and reduction from SNF level of care bills for Medicare
beneficiaries admitted prior to the termination of their agreement, or prior to the denial of
payments for new admissions.
70.3 - Part B Billing
(Rev. 767, Issued: 12-02-05, Effective: N/A, Implementation: N/A)
Following termination of its agreement, a SNF is considered to be a “nonparticipating
provider.” An inpatient of such a SNF who has Part B coverage, but for whom Part A
benefits have been exhausted or are otherwise not available, is entitled to payment only
for those services that are covered in a nonparticipating institution. Do not bill Part A
services furnished on or after the effective date of termination.
80 - Billing Related to Physician’s Services
(Rev. 2245, Issued: 06-16-11, Effective: 08-01-11, Implementation: 08-01-11)
Normally physicians are responsible for billing for their own services.
The services of facility-based physicians (e.g., those on a salary or percentage
arrangement, lessors of departments, etc., whether or not they bill patients directly)
include two distinct elements - the professional component and the provider component.
The professional component of facility-based physicians’ services includes services
directly related to the medical care of the individual patient. SNFs cannot bill for the
professional components of physician services, these must be billed under a physician
provider number to the A/B MAC (B). The technical component (e.g. the component
representing the performance of the diagnostic procedure itself) of physician services
delivered to SNF inpatients are bundled into the Part A PPS payment and not paid
separately.
A - Podiatry Services
Covered professional services rendered by facility-based podiatrists to individual patients
are covered only as physicians’ services under Part B. Note that certain foot care services
are excluded under both Part A and Part B. Payments to podiatrists for noncovered
services are not allowable Medicare costs regardless of whether the podiatrist’s
professional services are covered under Part B.
80.1 - Reassignment Limitations
(Rev. 1, 10-01-03)
SNF-507

Assigned benefits for physician’s services may not be paid to anyone other than the
physician who furnished the services, except:
• 	To the employer of the physician who provided the service, if such physician is
required as a condition of his employment to turn over his fee for the service to
his employer. (See §80.2 below.)
• 	To a facility in which the service is provided if there is a contractual arrangement
between the facility and the physician furnishing the service under which only the
facility can bill for the service. (See §80.3 below.)
• 	To an organization, which furnishes health care through an organized health care
delivery system (e.g., a freestanding physician clinic, or prepaid group practice
prepayment plan) if there is a contractual arrangement between the organization
and the physician furnishing the service under which only the organization can
bill for the service.
80.2 - Payment to Employer of Physician
(Rev. 1, 10-01-03)
SNF-508, SNF-510
Subject to the conditions and limitations described below, payment of Part B benefits due
a physician under assignment for services furnished in a facility may be made to the
facility if the facility and physician have an agreement under which only the facility may
bill and receive fees or amounts charged for the services.
40.1
Form CMS-855R must be completed to describe the arrangement with the facility. This
form and instructions for completing it can be downloaded from the CMS Forms Web
page. See the Medicare Program Integrity Manual for processing instructions after
completion.
The contractual arrangement between the facility and a physician may apply to all
services the physician furnishes in the facility, or merely to a particular category of
services that is clearly distinguishable from other categories. The distinction between the
categories must be consistent with proper determination of Part B reimbursement and
may not be based on whether the patient has Medicare.
While the law permits physicians to reassign to a facility the Part B benefits for the
patient care services they perform in the facility, this exception in favor of the facility is
intended to apply to an arrangement in which the facility obtains a significant degree of
control or interest in the disposition of the benefits. Under the law, Medicare benefits
cannot be paid to a facility under terms that make the facility a mere conduit for payment
to another person or entity.
EXAMPLE

Under an agreement between a facility and a partnership of teaching physicians, the
facility bills and receives payment in its name for the physician services but is required to
turn over to the partnership all fees received, less a small deduction to defray billing
expenses. The partnership distributes the monies received among its physician members
in accordance with the partnership agreement. Since the SNF functions under the
agreement as a mere conduit for payment to the partnership, the agreement is not an
acceptable contractual arrangement for purposes of the exception to the prohibition on
reassignment.
80.3 - Information Necessary to Permit Payment to a Facility
(Rev. 1, 10-01-03)
SNF-510.1
A facility may ordinarily qualify to receive Part B payment for the services of physicians
in the facility by submitting a Form CMS-855R to its A/B MAC (A), certifying that it
will bill for their services only as called for by its written contractual arrangements.
For purposes of Medicare benefits payable for the services, this agreement may be
terminated by either party upon written notice to the other, but such termination is not
binding upon Medicare until two weeks after the A/B MACs (A) receives a revised Form
CMS-855R notice of this termination.
80.4 - Services Furnished Within the SNF
(Rev. 1, 10-01-03)
SNF-510.2
The term “facility” is limited for purposes of furnishing services to individuals as
inpatients, e.g., hospitals, university medical centers that own and operate hospitals,
SNFs, nursing homes, homes for the aged, or other institutions of a similar nature.
Physician services furnished outside the physical premises of the facility are considered
furnished in the SNF if furnished in connection with services received by patients in the
SNF. For example, if SNF inpatients are taken to the private office of a neurologist for
necessary tests such as an encephalograph, the services are considered performed in the
SNF for billing and payment.
80.5 - Billing Under Arrangements
(Rev. 1, 10-01-03)
SNF-510.2
A provider may have others furnish certain covered items and services to their patients
through arrangements under which receipt of payment by the provider for the services
discharges the liability of the beneficiary or any other person to pay for the service. In
permitting providers to furnish services under arrangements, it is not intended that the
provider merely serve as a billing mechanism for the other party. Accordingly, for
services provided under arrangements to be covered, the provider must exercise
professional responsibility over the arranged-for services. See the Medicare General

Information, Eligibility, and Entitlement Manual, Chapter 5, “Definitions,” §10.3, for
additional discussion on services furnished under arrangement.
The law is silent regarding specific terms of a SNF’s payment to the outside provider or
supplier and currently does not authorize the Medicare program to impose any
requirements in this regard. Thus, the issue of the outside provider or supplier’s payment
by the SNF is a private, contractual matter that must be resolved through direct
negotiations between the parties. However, services provided under consolidated billing
arrangements must be provided by Medicare certified providers that are licensed to
provide the service involved. In addition, payment may not be made if the provider or
supplier is subject to OIG sanctions that would prohibit Medicare payment for the service
if the provider or supplier were billing independently.
In some cases, SNFs may purchase services for their patients from a hospital “under
arrangements.” Such services may include a physician component. When the physician
has entered into a valid contractual arrangement with the hospital in which his/her
services are furnished for it to bill for the services, no additional written authorization is
needed for SNFs to bill for his/her services. For example, where SNFs arrange to obtain
an EKG interpretation from Hospital B, and Hospital B has a valid contractual
arrangement with its cardiologist authorizing it to bill for his/her services, SNFs do not
need written authorization from the cardiologist to bill Medicare for the cost of the
services.
See the Medicare Benefit Policy Manual, Chapter 8, “Coverage of Extended Care (SNF)
Services Under Hospital Insurance,” §70.4, for additional information on services under
arrangements.
80.6 - Indirect Contractual Arrangement
(Rev. 1, 10-01-03)
SNF-510.3
The necessary contractual arrangement between physicians and the facility in which they
perform their services may exist indirectly by reason of the terms of their relationship
with an employer and the employer’s contractual arrangement with the facility.
EXAMPLE
A professional corporation enters into a contractual arrangement with an SNF to provide
physician services for it. Under this arrangement, the SNF alone bills and receives
payment for the physician services and pays the corporation a percentage of the charges.
The corporation, in turn, employs several physicians to provide the services, and under
the terms of their employment, is entitled to any fees payable for the services (other than
the portion of the fees retained by the SNF). The combination of the two arrangements -
between the SNF and the corporation and the corporation and the physicians - constitutes
an indirect contractual arrangement between the SNF and the physicians. For the SNF to
bill and receive payment for the physician services furnished in the SNF, the SNF must
also enter into a direct contractual arrangement with the physicians for this purpose.

80.7 - Establishing That a SNF Qualifies to Receive Part B Payment on
the Basis of Reassignment
(Rev. 1, 10-01-03)
SNF-512
A SNF wishing to receive Part B payment as a reassignee of one or more physicians must
furnish the A/B MAC (B) sufficient information to establish clearly that it qualifies or
does not qualify to receive payment for their services. Where there is any doubt that a
SNF qualifies as a reassignee, A/B MACs (B) will obtain additional evidence.
In some cases, a SNF may qualify to receive payment for the services of a physician both
as the employer of the physician and as the facility in which the services are performed.
As soon as it is determined that a SNF can qualify on either basis, no further development
is undertaken with respect to that physician or to other physicians having the same status,
and reassigned claims submitted by the SNF for services furnished by those physicians
are honored. However, where other physicians have, or appear to have different status,
further development is required. It is possible in some instances that a determination is
made that Part B payment can be made only to the physician himself.
Where the SNF qualifies as a reassignee, it assumes the same liability for any
overpayments that it may receive as a reassignee as the physician would have had if the
payment had been made to him/her.
90 - Medicare Advantage (MA) Beneficiaries
(Rev. 1252, Issued: 05-25-07; Effective: 10-01-06; Implementation: 08-27-07)
For billing to MA plans, SNFs follow the requirements of the agreement they have with
the plans. In cases where the patient may have enrolled or disenrolled from the plans
during the billing period, the SNF will split the bill and send the plan’s portion to it and
the remaining portion to the A/B MAC (A).
90.1 - Beneficiaries Disenrolled from MA Plans
(Rev. 1618, Issued: 10-24-08, Effective: 04-01-09; Implementation: 04-06-09)
If a beneficiary voluntarily or involuntarily dis-enrolls from a risk MA plan while an
inpatient of an SNF and converts to original Medicare (i.e., fee for service) the
requirement for a three day hospital stay will be waived if the beneficiary meets the level
of care criteria found in 42 CFR 409, Subpart D, up through the effective date of dis-
enrollment. The beneficiary will then be eligible for the number of days that remain out
of the 100 day SNF benefit for that particular SNF stay minus those days that would have
been covered by the program under original Medicare while the beneficiary was enrolled
in the risk MA plan. However, in cases where the beneficiary disenrolls from a risk MA
plan after discharge from the SNF, and then is readmitted to the SNF under the 30 day
rule, all requirements for original Medicare (i.e., fee for service), including the 3-day

hospital stay must be met. Rules regarding cost sharing apply to these cases. That is,
providers may only charge beneficiaries for SNF coinsurance amounts.
If the beneficiary voluntarily disenrolls from a risk MA plan and converts to original
Medicare (i.e., fee for service) before admission to a SNF then the beneficiary must meet
all original Medicare requirements for a SNF stay, including that of a three day inpatient
hospital stay.
SNFs submit all applicable fee-for-service inpatient SNF claims with condition code “58”
to indicate a patient was disenrolled from an MA plan and the 3-day prior stay
requirement was not met. Claims with condition code 58 will not require the 3-day prior
inpatient hospital stay. The A/B MAC (A) must use CWF files to validate the beneficiary
was enrolled in an MA organization upon admission to the SNF and that the MA
enrollment period ended prior to the “from” date on the claim. The A/B MAC (A) does
not need to verify that the MA plan was the one that terminated.
90.2 - Medicare Billing Requirements for Beneficiaries Enrolled in MA
Plans
(Rev.4491, Issued: 01-09- 20, Effective: 04-01-20, Implementation: 04-06-20)
If a beneficiary chooses an MA plan as his or her form of Medicare, he/she cannot look to
traditional “fee for service” Medicare to pay the claim if the MA plan denies coverage.
SNF providers shall apply the following policies to MA beneficiaries who are admitted to a
SNF:
• If the SNF is non-participating with the plan, the beneficiary must be notified of his or her
status because he/she MAY be private pay in this circumstance, depending upon the type of
MA plan in which he/she is enrolled;
• If the SNF is participating with the plan, pre-approve the SNF stay with the plan;
• If the plan denies coverage, appeal to the plan, not to the “fee for service” FI;
• Count the number of days paid by the plan as Part A days used (this IS the beneficiary’s
100 days of Medicare SNF benefits);
• Submit a claim to the “fee for service” A/B MAC (A) to subtract benefit days from the
CWF records. (Note: The plans do not send claims to CWF for SNF stays). Failure to send a
claim to the A/B MAC (A) will inaccurately show days available.
• If a beneficiary no longer requires skilled care under the MA plan the SNF may discharge
the patient using a patient status code 04. No- payment bills are not required for beneficiaries
that are receiving non-skilled care and are enrolled in an MA plan. If the beneficiary again
requires skilled care after a period of non-skilled care, the provider should begin a new
admission claim for Medicare to continue the spell of illness.
Billing Requirements

• Submit covered claims and include a HIPPS code (use default code AAA00 prior to
10/1/2019 and ZZZZZ after 10/1/2019) if no assessment was done), room and board charges
and condition code 04.
NOTE: If the beneficiary drops his or her MA plan participation during their SNF stay, the
beneficiary is entitled to coverage under Medicare FFS for the number of days available that
remain out of the 100 days available under the SNF benefit.
100 - Part A SNF PPS for Hospital Swing Bed Facilities
(Rev. 1, 10-01-03)
PM A-02-016
Section 4432(a) of the Balanced Budget Act (BBA) of 1997 specifies that swing bed
facilities must be incorporated into Part A SNF PPS by the end of the statutory transition
period. Effective with cost reporting periods beginning on or after July 1, 2002, swing
bed bills are not paid on the cost-based method, but rather on the basis of the Part A SNF
PPS. These payment rates cover all payment for furnishing covered swing bed extended
care services (routine, ancillary, and capital-related costs) other than approved
educational activities as defined in 42 CFR 413.85.
Part A SNF PPS applies to short-term hospitals, long-term care hospitals, and
rehabilitation hospitals that have Medicare swing bed agreements. CAHs with swing
beds are exempt from the Part A SNF PPS, and are not affected by these instructions.
The Part A PPS is phased in based on each swing bed hospital’s fiscal year. The
transition to Part A PPS is effective with the start of the provider’s first cost reporting
period that begins on or after July 1, 2002. Consequently, billing for all beneficiaries in a
swing bed must be split at the end of the provider’s fiscal year. A new bill is created for
beneficiaries remaining in the facility at the start of the new fiscal year. The bill must be
prepared under the Part A PPS claim guidelines described in this chapter and in Chapter
1, “General Billing Requirements.” Payment is made according to the instructions for
SNFs under Part A PPS found in the Medicare Provider Reimbursement Manual.
Providers of swing bed services submit Part A inpatient claims using TOB 18X.
The swing bed program does not include an inpatient Part B benefit. For beneficiaries
who continue to receive extended care services after the end of a Part A stay (e.g.,
benefits exhausted, not receiving a skilled level of care, etc.), ancillary services may be
billed under the hospital as inpatient Part B services.
If the beneficiary remains a resident in the swing bed facility after the end of the Part A
stay, the hospital may submit a claim to the A/B MAC (A) for those inpatient services
covered by Part B using TOB 12X. The beneficiary would be eligible for the same
benefits available to a hospital inpatient in a Part B stay. The hospital provider of SNF

level swing bed services must also file a Part A nonpayment bill monthly using the
appropriate nonpayment code.
For Part A PPS purposes, A/B MACs (A) assign swing bed hospitals to provider type 38
on their Provider-Specific File. Swing bed providers will be paid at 100 percent of the
Federal rate. Swing bed claims will be paid using the actual MSA code (based on county
codes), and the related rural or urban rate tables. A/B MACs (A) must set the Federal
PPS Blend Indicator in the Provider-Specific file to “4.” The CMI ADJ CPD field should
be blank.
Unless exceptions are noted, instructions applicable to SNFs are also applicable to swing
bed providers e.g., demand bills, spell of illness, covered and noncovered days,
nonpayment bills, and adjustment bills.
100.1 - Swing Bed Services Not Included in the Part A PPS Rate
(Rev. 4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19)
PM A-02-016
For their SNF-level inpatients, rural (non-CAH) swing bed hospitals must submit all
services that are not specifically excluded from consolidated billing on their Part A swing
bed bill (TOB 18x). However, they are eligible for additional payment outside the
bundled SNF PPS rate for those services that are excluded from the SNF Part A
consolidated billing requirements. Further, because the swing bed hospital itself still
remains subject to the hospital bundling requirements specified in §1862(a)(14) of the
Act and in 42 CFR 411.15(m), it retains the Medicare billing responsibility for any
excluded services to which the hospital bundling provision applies. Accordingly, it
would use a separate inpatient Part B claim to bill for such services (see §10.2 of this
chapter).
As noted above, if a swing bed hospital furnishes a service or supply to a beneficiary
receiving SNF-level services, which is excluded from the Part A PPS rate, the swing bed
hospital may submit a separate bill to the A/B MAC (A) for the SNF PPS-excluded
service. This bill must use TOB 13x with all appropriate revenue codes, HCPCS codes,
and line item date of service billing information and will be paid as inpatient Part B
services under the Outpatient Prospective Payment System (OPPS). (By contrast, those
services bundled into the SNF PPS rate may not be billed separately, and must all be
included on the Part A swing bed bill (TOB 18x).) A list of services that are excluded
from the SNF PPS rate is found in §§20.1 - 20.4 above.
Likewise, swing bed hospitals may file bills with the A/B MAC (A) for Part B Ancillary
services furnished to beneficiaries who are not in a Part A PPS swing bed stay. Such
claims are billed as inpatient Part B services, and are paid under the OPPS.

110 - A/B MAC (B)/DME MAC Claims Processing for Consolidated
Billing for Physician and Non-Physician Practitioner Services Rendered
to Beneficiaries in a SNF Part A Stay
(Rev. 1757, Issued: 06-19-09, Effective: 07-20-09, Implementation: 07-20-09)
For an overview of SNF consolidated billing, including types of facilities and services
subject to consolidated billing, see sections 10 and 20.
110.1 - Correct Place of Service (POS) Code for SNF Claims
(Rev. 76, 02-06-04)
Place of Service (POS) code 31 should be used with services for patients in a Part A
covered stay and POS code 32 should be used with services for beneficiaries in a
noncovered stay. A/B MACs (B) should adjust their prepayment procedure edits as
appropriate.
110.2 - CWF Edits
(Rev. 76, 02-06-04)
The following edits have been implemented in CWF.
110.2.1 - Reject and Unsolicited Response Edits
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary’s Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
A. Reject Edits
When CWF receives a bill from the SNF that shows that a beneficiary became a resident
of a SNF, that SNF stay is posted to history. Effective April 2002, for claims processed
and adjusted with dates of service on or after April 1, 2001, CWF will apply the reject
edits to any claims received after the SNF stay is posted that have dates of service during
the periods the beneficiary is shown to have been a resident of the SNF based on that first
SNF bill. These claims can be correctly rejected since it will be clear that the beneficiary
was in the SNF during those spans that were shown on the SNF claim. This process will
repeat when the next SNF bill is received. The process will continue until CWF posts a
discharge date, date of death, or the covered number of SNF days has been used.
Based on the CWF line item rejects, A/B MACs (B)/DME MACs must deny assigned
and unassigned services they have been billed that should have been consolidated and
paid by the SNF and/or billed to the A/B MAC (A). Appeals rights must be offered on

all denials. Shared systems must develop, and along with A/B MACs (B)/DME MACs
must implement, an automated resolution process whereby when they receive a reject
from CWF, they must pay those services correctly billed and only deny those services on
the claim incorrectly billed to them.
B. Unsolicited Response Edits
Effective July 1, 2002, CWF implemented the unsolicited response edit based on the
same coding files made available for the reject edits. Upon receipt of a Part A SNF claim
at CWF, CWF searches paid claims history and compares the period between the SNF
from and through dates to the line item service dates of the claims in history. It then
identifies any services within the dates of the SNF stay that should have been subject to
consolidated billing and should not have been separately paid by the A/B MAC (B)/DME
MAC.
The CWF generates an unsolicited response, with a trailer that contains the identifying
information regarding the claim subject to consolidated billing and a new trailer
containing line item specific information that identifies all the individual services on that
claim that fall within the SNF period. The unsolicited response provides all necessary
information to identify the claim, including Document Control Number, Medicare
beneficiary identifier, beneficiary name, date of birth, and beneficiary sex. CWF
electronically transmits this unsolicited response to the A/B MAC (B)/DME MAC that
originally processed the claim with consolidated services. These unsolicited responses
are included in the CWF response file. The unsolicited responses in that file for claims to
be adjusted for consolidated billing are identified with a unique transaction identifier.
The previously paid claim is not canceled and remains on CWF paid claims history,
pending subsequent adjustment.
Upon receipt of the unsolicited response, the shared system software reads the line item
information in the new trailer for each claim and performs an automated adjustment to
each claim. Services subject to consolidated billing must be denied at the line level. The
adjusted claims must then be returned to CWF, so that the claim on CWF paid claims
history is replaced with the adjusted record. A/B MACs (B)/DME MACs must return the
claims with entry code 5. Both the covered and the non-covered services must be
returned to CWF on the adjustment claim.
When CWF adjusts the claim on history, the deductible is updated on the beneficiary’s
file and the corrected deductible information is returned to the A/B MAC (B)/DME MAC
in trailer 11. To recover any monies due back to Medicare resulting from these denials,
A/B MACs (B)/DME MACs must follow the criteria in current overpayment recovery for
the policy guidelines for furnishing demand letters and granting appeals rights.
In cases where all services on the claim are identified in CWF as subject to consolidated
billing, the claim is adjusted by the standard system to line item deny all the services on
the claim. These fully non-covered claims must be returned to CWF, in order to reflect
the denial actions in CWF paid claims history and to update the information in CMS’s

national claims history file. A/B MAC (B)/DME MAC systems must employ existing
processes for the submission of fully non-covered claims.
110.2.2 - A/B Crossover Edits
(Rev. 1757, Issued: 06-19-09, Effective: 07-20-09, Implementation: 07-20-09)
Effective April 1, 2002, CWF implemented the following crossover edits for A/B MAC
(B) submitted claims. Automated processes were implemented for the resolution of these
edits based on the codes returned in the trailers from CWF.
A. Edits 7258 and 7259 - Part B Physical Therapy Claim Against an Inpatient SNF
21x and Inpatient Part B 22x Claim
Reject if an A/B MAC (B) claim is received containing physical therapy (type of service
of W), occupational therapy, or speech-language pathology and From/Thru Dates overlap
or are within the From/Thru Dates on an SNF inpatient claim (21x) or an inpatient Part B
claim (22x).
Use separate error codes where (1) dates are within (A/B MAC (B) will reject claim) or
(2) where dates overlap (A/B MAC (B) will automate a separate denial message to
provider).
Bypass the edit in the following situations:
• 	The 21x or 22x type of bill contains a cancel date.
• 	The incoming claim from date equals the SNF 21x or 22x history claim discharge
date or incoming through date equals the SNF 21x or 22x history claim
admission date.
Effective for claims with dates of service on or after April 1, 2001, CWF implemented
revisions on January 2, 2008 to bypass the edits 7258 and 7259 when a therapy claim
with a date of service on or after April 1, 2001 is submitted and the date of service is
within the From/Thru dates of an occurrence Span code date of 74 reported on a SNF
inpatient claim 21x in history. This will allow for services to be separately payable
outside of SNF consolidated billing during non-covered periods in the SNF.
Effective for claims with dates of service on or after April 1, 2001, CWF implemented
revisions on April 7, 2008 to modify the existing therapy edit for Part B claims
processing for non-covered SNF stays to read claims history to look for a 21x (SNF
Inpatient) bill type that contains an Occurrence Code 22 (Date Active Care Ended) and a
Patient Status Code 30 (Still patient or expected to return for outpatient services) where
there is no subsequent 21x (SNF inpatient) bill type discharge claim from the same
provider. As therapy services provided in a SNF must be consolidated when a
beneficiary is in either a covered or non-covered stay, CWF will reject claims with dates
of service after the posted SNF claim containing Occurrence Code 22 (Date Active Care
Ended) and Patient Status 30 (Still patient or expected to return for outpatient services)

until a 21x (SNF inpatient) bill type discharge claim is processed. The entity furnishing
the therapy services must look to the SNF for reimbursement rather than the A/B MAC
(A) or (B). For claims processed on or after January 5, 2009, this edit shall no longer be
functional. A/B MACs (A) and (B) shall re-open and-re-process claims previously
denied due to this edit when brought to their attention should they determine that the
beneficiary was not in a SNF stay during the period the therapy service was
rendered.
B. Edits 7260 and 7261 - Part B Claim Without Therapy Against an Inpatient SNF
Reject if a Part B claim is received with From/Thru Dates overlapping or are within the
From/Thru Dates on an SNF Inpatient claim (21x). If the SNF 21x claim on history has
patient status 30 and occurrence code 22 (Date Active Care Ended), use occurrence 22
date instead of the through date.
Use separate error codes where (1) dates are within (A/B MAC (B) will reject claim); or
(2) where dates overlap (A/B MAC (B) will automate a separate denial message to
provider).
Bypass the edit in the following situations:
• 	The 21x history claim contains a cancel date.
• 	The incoming A/B MAC (B) claim from date equals the SNF 21x history claim
discharge date. The incoming A/B MAC (B) claim through date equals the SNF
21x history claim admission date.
• 	A diagnosis code in any position on the incoming claim is for renal disease.
• 	The A/B MAC (B) claim contains ambulance codes per the files supplied to CWF
in the annual and quarterly updates with modifiers other than N (SNF) in both the
origin and destination on the same claim.
• 	The A/B MAC (B) claim is a CANCEL ONLY (Action Code 4) claim.
• 	The A/B MAC (B) claim is denied.
• 	The A/B MAC (B) service has a Payment Process Indicator other than A
(allowed).
• 	The A/B MAC (B) claim contains only separately payable services per the files
supplied to CWF in the annual and quarterly updates.
Effective for claims with dates of service on or after April 1, 2001, CWF implemented
revisions on January 2, 2008 to bypass the edits 7260 and 7261 when a claim with a date
of service on or after April 1, 2001 is submitted and the date of service is within the

From/Thru dates with an occurrence Span code date of 74, 76, 77, 79, or M1 reported on
a SNF inpatient claim 21x in history or the date of service is greater than the occurrence
date on a SNF inpatient claim 21x in history with an occurrence code date of A3, B3, or
C3. This will allow for services to be separately payable outside of SNF consolidated
billing during non-covered periods in the SNF.
110.2.3 - Duplicate Edits
(Rev. 1757, Issued: 06-19-09, Effective: 07-20-09, Implementation: 07-20-09)
Effective April 1, 2002, CWF implemented the following duplicate edits for A/B MAC
(B) submitted claims.
A. Edit 7253 - Part B Ambulance Claim Against an Outpatient Part B SNF
Ambulance Claim on History
Reject if a Part B claim is received with ambulance codes per the files supplied to CWF
in the annual and quarterly updates and the Date of Service equals the Date of Service on
an outpatient Part B SNF (23x) claim with revenue code 54x (ambulance).
Bypass the edit if either the incoming or history claim contains any of the following
situations:
• 	The claim is a CANCEL ONLY (Action Code 4) claim.
• 	The claim is denied.
• 	The incoming claim payment process indicator is other than A (allowed).
B. Edit 7257 - A/B MAC (B) or DME MAC or A/B MAC (A) Part B Claim Against
An Inpatient B SNF (22x) Claim on History
Reject as a duplicate claim if an A/B MAC (B) or DME MAC Part B claim or A/B MAC
(A) Part B claim (12x, 13x, 14x, 23x, 33x, 71x, 73x, 74x, 75x, 76x, 83x or 85x) is
received containing date of service, HCPCS code and modifier if present, equal to the
date of service, HCPCS code and modifier, if present, on an inpatient Part B SNF (221,
222, 223, 224 or 225) claim.
Bypass the edit if either the incoming or history claim contains any of the following
situations:
• 	The claim is a CANCEL ONLY (Action Code 4) claim.
• 	The claim is denied.
• 	HCPCS code is not present on the A/B MAC (A) claim.
• 	The A/B MAC (B) Part B claim payment process indicator is other than A
(allowed).
• 	For the A/B MAC (B)/DME MAC claim only, the Part B claim contains only
separately payable services per the files supplied to CWF in the annual and
quarterly updates.

110.2.4 - Edit for Ambulance Services
(Rev. 1757, Issued: 06-19-09, Effective: 07-20-09, Implementation: 07-20-09)
When a medically necessary transport from one SNF to another SNF occurs when the
beneficiary is discharged from the first SNF and admitted to the second, this transport is
included in consolidated billing. The first SNF is responsible for the ambulance service
and the cost is included in the Part A rate. It is not separately billable. CWF will reject
these services to the A/B MAC (B). The A/B MAC (B) must deny the service with
appeals rights.
Effective for claims with dates of service on or after April 1, 2001, CWF implemented
revisions on January 2, 2008 to bypass edit 7275 when a claim with a date of service on
or after April 1, 2001 is submitted and the date of service is within the From/Thru dates
with an occurrence Span code date of 74, 76, 77, 79, or M1 reported on a SNF inpatient
claim 21x in history or the date of service is greater than the occurrence date on a SNF
inpatient claim 21x in history with an occurrence code date of A3, B3, or C3. This will
allow for services to be separately payable outside of SNF consolidated billing during
non-covered periods in the SNF.
110.2.5 - Edit for Clinical Social Workers (CSWs)
(Rev. 3481, Issued: 03-18-16. Effective: 06-20-16, Implementation: 06-20-16)
Per the Balanced Budget Act, services provided by CSWs to beneficiaries in a Part A
SNF stay may not be billed separately to the A/B MAC (B). Payment for these services
is included in the prospective payment rate paid to the SNF by the A/B MAC (A).
Though the policy was in effect since April 1, 2001, there were no corresponding edits.
With the April 2003 release, CWF implemented a new SNF consolidated billing edit to
prevent payment to CSWs for services rendered to beneficiaries in a Part A SNF stay.
Effective April 1, 2003, CWF established the new edit 7269 for services rendered to these
beneficiaries with dates of service on or after April 1, 2001, for claims received on or
after April 1, 2003. Once CWF determines that a beneficiary is in a Part A stay, prior to
applying the edits that review procedure codes to determine if payment should be
allowed, CWF will review the performing provider type of the submitting entity. If the
performing provider type is 80, CWF will reject the claim to the A/B MAC (B) or return
an unsolicited response with new error code 7269. The A/B MAC (B) will then take the
same adjustment and recovery action as for other rejects and unsolicited responses.
When A/B MACs (B) receive the new reject code, they must deny the claim and use the
following RA and MSN messages.
The contractor shall use the following remittance advice messages and associated codes
when rejecting/denying claims under this policy. This CARC/RARC combination is
compliant with CAQH CORE Business Scenario Three.
Group Code: CO

CARC: 96
RARC: N121
MSN: 13.10
Effective for claims with dates of service on or after April 1, 2001, CWF implemented
revisions on January 2, 2008 to bypass edit 7269 when a claim with a date of service on
or after April 1, 2001 is submitted and the date of service is within the From/Thru dates
with an occurrence Span code date of 74, 76, 77, 79, or M1 reported on a SNF inpatient
claim 21x in history or the date of service is greater than the occurrence date on a SNF
inpatient claim 21x in history with an occurrence code date of A3, B3, or C3. This will
allow for services to be separately payable outside of SNF consolidated billing during
non-covered periods in the SNF.
110.2.6 - Edit for Therapy Services Separately Payable When Furnished
by a Physician
(Rev. 1757, Issued: 06-19-09, Effective: 07-20-09, Implementation: 07-20-09)
A number of therapy services are considered separately payable when provided by a
physician and shall be paid separately by the A/B MAC (B). However, these services are
considered therapy when provided by a physical or occupational therapist and are subject
to consolidated billing.
Effective for claims with dates of service on or after July 1, 2004, edits will be
implemented in the claims processing system to correctly process claims for these
services. A complete list of these services can be found on the CMS website at
https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/.
110.2.7 - Edit to Prevent Payment of Facility Fees for Services Billed by
an Ambulatory Surgical Center (ASC) when Rendered to a Beneficiary
in a Part A Stay
(Rev. 1911; Issued: 02-05-10; Effective Date: 01-01-08; Implementation Date: 07-
06-10)
The Balanced Budget Act (BBA) of 1997 required the implementation of a SNF
prospective payment system and the consolidated billing of services provided to residents
of the SNF. Facility services provided by a freestanding non-hospital ASC are included
under the SNF CB provisions. This edit will prevent payment of those facility services
when provided in an ASC to a beneficiary in a Part A SNF CB stay.
Effective for claims with dates of service on or after January 1, 2008 that are processed
on or after July 6, 2010, when CWF receives a claim for a facility service from an ASC
that is enrolled as a provider specialty type 49, and the service has a Type of Service F,
and the patient is in a Part A SNF stay, it shall notify the A/B MACs (B) that they shall
reject the claim line for the service(s). It shall send the same trailer that is currently sent
for services subject to SNF consolidated billing. (The services subject to this editing will
also appear on the ASC Fee schedule.)

Also, when CWF receives a Part A SNF claim, it shall also notify A/B MACs (A), (B), or
(HHH), and DME MACs through an unsolicited response of any facility services as
described above that were incorrectly paid. MACs shall follow current processes to
recoup any overpayments.
A/B MACs (A), (B), (HHH), or DME MACs shall return the same messages found in
Section 110.2.1C.
110.3 - CWF Override Codes
(Rev. 1757, Issued: 06-19-09, Effective: 07-20-09, Implementation: 07-20-09)
A CWF override code has been developed for A/B MAC (B) or DME MAC use where,
in the course of pursuing a reconsideration, a provider or supplier may bring to the
attention of the A/B MAC (B) a situation where services on a claim have been denied,
but should actually be allowed to be paid through the A/B MAC (B)/DME MAC. At the
A/B MAC (B)/DME MAC’s discretion, to allow that claim to process through CWF to
payment, enter a “2” in the SNF consolidated billing override field.
110.4 - Coding Files and Updates
(Rev. 1757, Issued: 06-19-09, Effective: 07-20-09, Implementation: 07-20-09)
To correspond with the annual and quarterly coding and payment updates, CWF will be
provided with files of codes that are not included in consolidated billing and can be paid
through the A/B MAC (B) or DME MAC. These codes are available for informational
purposes on the CMS Web site at https://www.cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/SNFPPS/ConsolidatedBilling.html. Changes in designation of codes
from excluded to included (or vice versa) in consolidated billing will be considered
corrections to align the codes with policy as opposed to changes in policy. Newly
established Healthcare Common Procedure Coding System codes will be added to CWF
edits to allow A/B MACs (B)/DME MACs to make appropriate payments.
110.4.1 - Annual Update Process
(Rev. 2802, Issued: 10-25-13, Effective: 01-01-14, Implementation: 01-06-14)
Barring any delay in the Medicare Physician Fee Schedule, CMS will provide the new
code files to CWF by November 1. Should this date change, CWF will be notified
through the appropriate mechanism. All future updates will be submitted via a Recurring
Update Notification form. These Recurring Update Notifications also describe how the
changes will be implemented.
CWF will be provided with 4 coding files (Physician Services, Professional Component
of Physician Services to be Submitted with the 26 Modifier, Ambulance, and Therapy)
that are effective based on dates of service January 1 through December 31 for that year.
New files shall be provided for each calendar year. Quarterly updates to the four files
will continue as usual.

A/B MACs (B)/DME MACs must continue to respond to rejects and unsolicited
responses received from CWF per current methodology.
A/B MACs (B)/DME MACs must reopen and reprocess any claims brought to their
attention for services that prior to this update were mistakenly considered to be subject to
consolidated billing and therefore, not separately payable. A/B MACs (B)/DME MACs
need not search claims history to identify these claims.
Prior to January 1 of each year, new codes files will be posted to the CMS Web site at.
https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/. Should this date
change, A/B MACs (B)/DME MACs will be notified through the appropriate mechanism.
Coding changes throughout the year may also be made as necessary through a quarterly
update process.
As soon as the new code files are posted to the CMS Web site, through their Web sites
and list serves, A/B MACs (B)/DME MACs must notify physician, non-physician
practitioners, and suppliers of the availability of the files.
120 - Skilled Nursing Facility (SNF) Patient Driven Payment Model
(PDPM)
(Rev. 4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19)
SNFs billing on Type of Bill (TOB) 21X and rural hospital (non-CAH) swing-bed
providers billing on TOB 18X (subject to SNF PPS), will be subject to these
requirements. Currently, under the SNF PPS, revenue code 0022 indicates that this claim
is being paid under the SNF PPS. This revenue code can appear on a claim as often as
necessary to indicate different Health Insurance Prospective Payment System (HIPPS)
Rate Code(s) and assessment periods. The HCPCS/Rates field must contain a 5-digit
“HIPPS Code”. Under the previous case-mix classification model, the Resource
Utilization Groups, version 4 (RUG-IV), the first three positions of the code contained
the RUG group, and the last two positions of the code contained a 2-digit assessment
indicator (AI) code.
120.1 - HIPPS Updates and Structure Changes
(Rev. 4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19)
Under PDPM, the HIPPS code is structured differently, as a result of there being five
case-mix adjusted rate components under the revised model. The first position represents
the Physical and Occupational Therapy case-mix group. The second position represents
the Speech-Language Pathology case-mix group. The third character represents the
nursing case-mix group. The fourth character represents the Non-Therapy Ancillary
(NTA) case-mix group. The fifth character represents the AI code. CMS would note that
this also affects the number of potentially valid HIPPS codes under PDPM, as compared
to RUG-IV.

The PPS assessment schedule under PDPM is also significantly different from that used
under RUG-IV. The only assessments under PDPM that would produce a HIPPS code
would be the initial Medicare (“5-day”) PPS assessment, which follows the same
schedule as under the previous RUG-IV model, and the optional Interim Payment
Assessment (IPA), which may be completed at any point during a PPS stay.
The initial SNF PDPM HIPPS Codes can be found online at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes.html
Note: AAA00 default will be replaced with ZZZZZ effective October 1, 2019.
120.2 - Interrupted Stay Policy
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)
PDPM includes an interrupted stay policy, which would combine multiple SNF stays into
a single stay in cases where the patient’s discharge and readmission occurs within a
prescribed window (i.e., interruption window), similar to that which exists currently in
many other Medicare inpatient facilities. Specifically, if a patient in a covered Part A
SNF stay is discharged from the SNF but returns to the SNF no later than 11:59pm of the
third consecutive calendar day after having left Part A coverage, then this would be
considered a continuation of the same SNF stay. In such cases, no new patient
assessments are required and the variable per diem adjustment is not reset. If the patient
returns to the same SNF outside the interruption window, or returns to a different SNF,
then this would be considered a new stay.
The interruption window begins on the first non-covered day following a Part A-covered
SNF stay and ends at 11:59pm on the third consecutive non-covered day. The first non-
covered day in this context may be different depending on whether the patient actually
leaves the facility or simply leaves Part A coverage. Specifically, if the patient physically
leaves the SNF, the first day of the interruption window would be the day of departure
itself, whereas if the patient simply discontinues Part A coverage but remains in the SNF,
the first day of the interruption window would be the day following the final day of Part
A coverage.
Specifying the endpoint of the interruption window’s third day as occurring at 11:59 pm
rather than at midnight is consistent with the regulations at 42 CFR 411.15(p)(3)(iv),
which define a beneficiary’s SNF “resident” status for consolidated billing purposes as
ending whenever he or she is formally discharged (or otherwise departs) from the SNF,
unless he or she is readmitted (or returns) to that or another SNF “. . . before the
following midnight” (emphasis added). See §10.1 of this chapter, and also see §20.1 in
the Medicare Benefit Policy Manual, Chapter 3, which specifies that in counting inpatient
days, “. . . a day begins at midnight and ends 24 hours later.” However, unlike similar
interrupted stay policies under some of the other prospective payment systems, the SNF
interrupted stay policy is not used in determining whether bundling would apply to
services furnished during the interruption. That determination would instead continue to

follow the longstanding set of rules under 42 CFR 411.15(p)(3) regarding SNF “resident”
status for consolidated billing purposes (see §§10ff.).
The day of discharge (as noted above, this date could be different if the patient leaves the
facility or simply leaves Part A coverage) is the FROM date and the last day the patient is
not in the SNF at midnight is the THROUGH date. Occurrence span code 74 should be
reported for each interruption of more than ONE day.
The interrupted stay would be recorded on the claim in the same manner as is done for
the IRF PPS, and as further discussed in the examples below.
Examples:
1) Patient is admitted to SNF on 11/07/19 and is in a covered Part A stay. Patient is
discharged from the SNF and admitted to the hospital on 11/20/19. Patient is readmitted
to the same SNF on 11/25/19 and is in a covered Part A stay. The readmission is a new
stay because more than 3 days have passed from the date the patient was discharged from
the SNF and the date the patient was readmitted to the same SNF.
New stay
Assessment Schedule: Reset; stay begins with new 5-day assessment.
Variable Per Diem (VPD): Reset: stay begins on Day 1 of VPD Schedule.
2) Patient is admitted to SNF on 11/07/19 and in a covered Part A stay. The patient is
discharged from Part A on 11/20/19 but remains in the facility. The patient returns to a
covered Part A stay on 11/22/19. This is a continuation of a previous stay because the
patient returned to a covered Part A stay within 3 days of being discharged from a
covered Part A stay.
Continuation of previous stay
Assessment Schedule: No PPS assessments required, IPA optional
VPD: Continues from Day 14 (Day of Part A Discharge).
Billing Example: Patient is admitted to SNF on 10/1/2019 and discharged to home on
12/25/2019, with an interrupted stay to an IPPS on 10/20/2019-10/22/2019. This was an
admission to an IPPS on 10/20/2019-10/22/2019.
10/1/2019 – 10/31/2019 first interim claim,
Claim must be billed with occurrence span code 74 and occurrence span dates 10/20 –
10/21/2019 to represent the interrupted stay,
11/1/2019 – 11/30/2019 second interim claim,
12/1/2019 – 12/25/2019 final interim claim,
(Occurrence span code 74 only appears on the claim in which its dates fall within the
statement covers period – in this example only on October claim).
• 	Accommodation revenue code 018x is reported during the interrupted stay and is
when the beneficiary is not present at the midnight census taking time.
• 	Occurrence span code 74 and date range for the interruption.

Days for the interruption shall be reported as non-covered, not to exceed 3 days or it will
be considered a new admission.
On the SNF Medicare bill, the presence of occurrence span code 74 indicates an
interrupted stay has occurred. Report occurrence span code 74 with the FROM and
THROUGH dates of the interruption in the stay. The day of discharge from the SNF is
the FROM date and the last day the patient is not in the SNF at midnight is the
THROUGH date. Report accommodation revenue code 18X (leave of absence) and the
quantity of leave days. Occurrence span code 74 should be reported for each interruption
of more than 1 day along with the dates of each interruption. Revenue code 018X should
reflect the total number of days for all occurrence span code 74 entries. In other words,
revenue code 018X should be listed on one line, with all interrupted days included in the
units column. No charges should be added to this charge line.
120.3 - Variable Per Diem (VPD) Adjustment
(Rev.4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19)
The Social Security Act requires that Medicare Part A-covered SNF stays be paid on a
per-diem basis. PDPM SNF PPS per diem payments will be reduced according to a
prescribed schedule, referred to as the VPD adjustment. Specifically, the PDPM provides
for an adjustment factor that is applied to certain components and changes the per diem
rate over the course of the stay.
Thus, under PDPM, the per diem rate for a given day of the SNF PPS stay may be
different from the prior day, depending on an adjustment factor that may be applied
against the SNF PPS rate connected with the HIPPS code. Moreover, the VPD schedule
applies only to the PT, OT, and NTA components of the per diem rate, with different
schedules for the PT/OT components than for the NTA component. A similar adjustment
exists under the Inpatient Psychiatric Facility (IPF) PPS.
For the PT, OT, and NTA components, the case-mix adjusted per diem rate is multiplied
against the variable per diem adjustment factor, following a schedule of adjustments for
each day of the patient’s stay
VPD Adjustment Schedules
PT & OT Components
Day in Stay 	Adjustment Factor 	Day in Stay 	Adjustment Factor

1-20 	1.00 	63-69 	0.86
21-27 	0.98 	70-76 	0.84
28-34 	0.96 	77-83 	0.82
35-41 	0.94 	84-90 	0.80
42-48 	0.92 	91-97 	0.78
49-55 	0.90 	98-100 	0.76
56-62 	0.88
NTA Component
Day in Stay 	Adjustment Factor
1-3 	3.00
4-100 	1.00
120.4 - AIDS Adjustments
(Rev. 4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19)
As under the previous RUG-IV model, patients with a “B20” ICD-10 diagnosis code on
the SNF claim, meaning the patient has AIDS/HIV, receive an adjustment factor for their
PPS rate. Under PDPM, the adjustment factor is different from that used under RUG-IV.
Rather than a 128 percent adjustment for the entire PPS per diem rate, the adjustment
under PDPM is an increase of 18 percent in the nursing component of the per diem rate
and a reclassification under the NTA component to a higher rate category.
All other adjustment factors, such as adjustments for geographic variation in wage costs,
remain the same under PDPM as under the previous RUG-IV model.
120.5 - Transition Claims
(Rev. 4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19)
With regard to transition between RUG-IV and PDPM, a hard transition between the two
systems has been implemented, such that days paid under RUG-IV would stop on
September 30, 2019 and days would be paid under PDPM beginning October 1, 2019.

In order to receive a RUG-IV HIPPS code that can be billed for services furnished prior
to October 1, 2019, providers must use an assessment with an ARD set for on or prior to
September 30, 2019.
If the patient’s stay begins on or after October 1, 2019, then the provider would begin
with the 5-day assessment, as usual.
For patients admitted prior to October 1, 2019, but whose stays continue past this date, in
order to receive a PDPM HIPPS code that can be used to bill for services furnished on or
after October 1, 2019, providers must complete an IPA with an ARD no later than
October 7, 2019 (i.e., transitional IPA):
October 1, 2019, will be considered Day 1 of the VPD schedule under PDPM, even if the
patient began their stay prior to October 1, 2019.
Any “transitional IPAs” with an ARD after October 7, 2019, will be considered late and
relevant penalty for late assessments would apply (described below).
120.6 - Default Billing
(Rev. 4409, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19)
As under RUG-IV, there may be instances in which providers may bill the “default” rate
on a SNF claim (e.g., when an MDS assessment is considered late).
• 	The default rate refers to the lowest possible per diem rate.
• 	The default code under PDPM is ZZZZZ, as compared to the default code under
RUG-IV of AAA00.
• 	Billing the default code under PDPM represents the equivalent of billing the
following PDPM groups:
PT Payment Group: TP
OT Payment Group: TP
SLP Payment Group: SA
Nursing Payment Group: PA1
NTA Payment Group: NF

Transmittals Issued for this Chapter
Rev# 	Issue Date 	Subject 	Impl Date 	CR#
R13089CP 	02/21/2025 	Manual Updates Regarding Home
Health Adjustments and Skilled
Nursing Facility, Home Health and
Hospice Pricer Information
05/22/2025 	13955
R12283CP 	10/05/2023 	Internet Only Manual Updates to
Pub. 100-02 and 100-04 to
Implement Consolidated
Appropriations Act 2023 Changes
for Skilled Nursing Facility (SNF)
01/08/2023 	13271
R11109CP 	11/04/2021 	Skilled Nursing Facility (SNF)
Claims Processing Updates
01/03/2022 	12344
R10904CP 	08/10/2021 	Skilled Nursing Facility (SNF)
Claims Processing Updates –
Rescinded and replaced by
Transmittal 11109
01/03/2022 	12344
R10880CP 	06/08/2021 	Internet Only Manual Updates to
Pub. 100-01, 100-02, and 100-04 to
Implement Consolidated
Appropriations Act Changes and
Correct Errors and Omissions (SNF)
11/08/2021 	12009
R10569CP 	01/14/2021 	Updates to Skilled Nursing Facility
(SNF) Patient Driven Payment
Model (PDPM) Claims
04/05/2021 	11992
R10448CP 	11/06/2020 	Updates to Skilled Nursing Facility
(SNF) Patient Driven Payment
Model (PDPM) Claims – Rescinded
and replaced by Transmittal 10569
04/05/2021 	11992
R10236CP 	07/31/2020 	Update to the IOM Publication (Pub)
100-04, Medicare Claims Processing
Manual, Chapters 1, 6, 8, 17, 20, 22,
24, and 31 Referencing the Active
Universal Resource Locators (URLs)
for the Washington Publishing
Company (WPC) and the ASC X12
Organizations, and Updates to the
HIPAA Eligibility Transaction
08/31/2020 	11857

Rev# 	Issue Date 	Subject 	Impl Date 	CR#
System (HETS)
R10222CP 	07/14/2020 	Updates in the Fiscal Intermediary
Shared System (FISS) Inpatient
Provider Specific Files (PSF)
10/05/2020 	11797
R10140CP 	05/15/2020 	Updates in the Fiscal Intermediary
Shared System (FISS) Inpatient
Provider Specific Files (PSF)-
Rescinded and replaced by
Transmittal 10222
10/05/2020 	11797
01/09/2020 	Updates to CR 11152
Implementation of the Skilled
Nursing Facility (SNF) Patient
Driven Payment Model (PDPM)
04/06/2020 	11513
R4409CP 	10/04/2019 	Manual Updates for CR11152
Implementation of the Skilled
Nursing Facility (SNF) Patient
Driven Payment Model (PDPM)
11/05/2019 	11454
R4247CP 	03/01/2019 	Update to Publication 100-04
Chapters 2, 6, and 18 to Provide
Language-Only Changes for the New
Medicare Card Project
04/01/2019 	11155
R4157CP 	11/02/2018 	Hospital and Critical Access Hospital
(CAH) Swing-Bed Manual Revisions
and Shared Systems Changes
04/01/2019 	10962
R4163CP 	11/02/2018 	Internet Only Manual Updates to
Pub. 100-01, 100-02 and 100-04 to
Correct Errors and Omissions (SNF)
(2018 Q4)
12/04/2018 	11004
R4001CP 	03/16/2018 	Internet Only Manual Updates to
Pub. 100-01, 100-02 and 100-04 to
Correct Errors and Omissions (SNF)
(2018)
06/19/2018 	4001
R3612CP 	09/16/2016 	Internet Only Manual Updates to
Pub. 100-01, 100-02 and 100-04 to
Correct Errors and Omissions (SNF)
10/18/2016 	9748

Rev# 	Issue Date 	Subject 	Impl Date 	CR#
R3481CP 	03/18/2016 	Updates to Pub. 100-04, Chapters 3,
6, 7 and 15 to Correct Remittance
Advice Messages
06/20/2016 	9562
R3379CP 	10/16/2015 	Internet Only Manual Updates to
Pub. 100-01, 100-02 and 100-04 to
Correct Errors and Omissions (2015)
11/16/2015 	9336
R3230CP 	04/03/2015 	Updates to the Medicare Internet-
Only Manual Chapters for Skilled
Nursing Facility (SNF) Providers
06/15/2015 	8997
R3220CP 	03/16/2015 	Update to Pub. 100-04, Chapters 5
and 6 to Provide Language-Only
Changes for Updating ICD-10, ASC
X12, and Medicare Administrative
Contractor (MAC) Implementation
09/16/2014 	8524
R3216CP 	03/13/2015 	Updates to the Medicare Internet-
Only Manual Chapters for Skilled
Nursing Facility (SNF) Providers –
Rescinded and replaced by
Transmittal 3230
06/15/2015 	8997
R3028CP 	08/15/2014 	Update to Pub. 100-04, Chapters 5
and 6 to Provide Language-Only
Changes for Updating ICD-10, ASC
X12, and Medicare Administrative
Contractor (MAC) Implementation –
Rescinded and replaced by
Transmittal 3220
09/16/2014 	8524
R2921CP 	04/04/2014 	Internet Only Manual Updates to
Pub. 100-01, 100-02 and 100-04 to
Correct Errors and Omissions
05/05/2014 	8669
R2899CP 	03/07/2014 	Pub 100-04, Language Only Update
for Chapters Five and Six for
Conversion to ICD-10
10/01/2014 	8524
R2815CP 	11/15/2013 	Updates to the Medicare Claims
Processing Internet-Only Manual
(IOM)
03/18/2014 	8490

Rev# 	Issue Date 	Subject 	Impl Date 	CR#
R2802CP 	10/25/2013 	2014 Annual Update of Healthcare
Common Procedure Coding System
(HCPCS) Codes for Skilled Nursing
Facility (SNF) Consolidated Billing
(CB) Update
01/06/2014 	8474
R2573CP 	10/26/2012 	Manual Updates to Clarify SNF
Claims Processing
04/01/2013 	8044
R2399CP 	01/26/2012 	Clarification for Skilled Nursing
Facility (SNF) and Swing Bed (SB)
Part A Billing - Updating System
Requirements for Assessment Date
Reporting and Removal of the
Occurrence Code 16 Reporting
Requirement
07/02/2012 	7717
R2377CP 	12/30/2011 	Manual Revision to Chapter 6,
Section 20.1.1 Physician’s Services
and Other Professional Services
Excluded From Part A PPS Payment
and the Consolidated Billing
Requirement
01/31/2012 	7658
R2245CP 	06/16/2011 	Manual Clarifications for Skilled
Nursing Facility (SNF) Part A
Billing
08/01/2011 	7339
R2239CP 	06/14/2011 	Manual Clarifications for Skilled
Nursing Facility (SNF) Part A
Billing – Rescinded and replaced by
Transmittal 2245
08/01/2011 	7339
R2183CP 	03/25/2011 	Manual Clarifications for Skilled
Nursing Facility (SNF) Part A
Billing – Rescinded and replaced by
Transmittal 2239
06/28/2011 	7339
R2028CP 	08/13/2010 	5010 Implementation--Processing
Additional International
Classification of Diseases, 9th
Revision-Clinical Modification
(ICD-9-CM) Diagnosis and
Procedure Codes in Pricer, Grouper,
01/03/2011 	7004

Rev# 	Issue Date 	Subject 	Impl Date 	CR#
and the Medicare Code Editor
(MCE)
R2016CP 	07/30/2010 	5010 Implementation--Processing
Additional International
Classification of Diseases, 9th
Revision-Clinical Modification
(ICD-9-CM) Diagnosis and
Procedure Codes in Pricer, Grouper,
and the Medicare Code Editor
(MCE) - Rescinded and replaced by
Transmittal 2028
01/03/2011 	7004
R2011CP 	07/30/2010 	Revised Instructions for Reporting
Assessment Dates under the Inpatient
Rehabilitation Facility (IRF), Skilled
Nursing Facility (SNF), and Swing
Bed (SB) Prospective Payment
Systems (PPS)
01/03/2011 	7019
R1958CP 	04/28/2010 	Skilled Nursing Facility (SNF)
Health Insurance Prospective
Payment System (HIPPS) Coding
Updates Effective October 1, 2010
10/04/2010 	6916
R1911CP 	02/05/2010 	Implementation of a New Skilled
Nursing Facility (SNF) Consolidated
Billing (CB) Edit for Facility
Services Billed by Ambulatory
Surgical Centers (ASCs)
07/06/2010 	6702
R1814CP 	09/04/2009 	2010 Annual Update of Healthcare
Common Procedure Code System
(HCPCS) Codes for Skilled Nursing
Facility (SNF) Consolidated Billing
(CB) Update
01/04/2010 	6619
R1757CP 	06/19/2009 	Claims Processing for Skilled
Nursing Facility Consolidated Billing
07/20/2009 	6521
R1749CP 	06/05/2009 	Revised Billing Instructions for
Occurrence Span Code 74 on Skilled
Nursing Facility (SNF) No Payment
Claims
10/05/2009 	6523

Rev# 	Issue Date 	Subject 	Impl Date 	CR#
R1733CP 	05/08/2009 	Manual Clarification for Skilled
Nursing Facility (SNF) and Therapy
Billing
04/27/2009 	6407
R1706CP 	03/27/2009 	Manual Clarification for Skilled
Nursing Facility (SNF) and Therapy
Billing – Rescinded and replaced by
Transmittal 1733
04/27/2009 	6407
R1618CP 	10/24/2008 	Revision to the Reporting
Requirements of Qualifying Hospital
Stays on Inpatient Skilled Nursing
Facility (SNF) and Swing Bed (SB)
Claims
04/06/2009 	6233
R1565CP 	07/25/2008 	Clarification on the Correct
Condition Code to Report on
Provider Adjustment Requests to
Indicate a Health Insurance
Prospective Payment System
(HIPPS) Code Change
01/05/2009 	6002
R1555CP 	07/18/2008 	Revision of the Requirements for
Denial of Payment for New
Admissions (DPNA) for Skilled
Nursing Facility (SNF) Billing
01/05/2009 	6116
R1554CP 	07/18/2008 	Revision to Skilled Nursing Facility
(SNF) Common Working File
(CWF) Editing
01/05/2009 	6128
R1553CP 	07/18/2008 	Clarification on the Correct
Condition Code to Report on
Provider Adjustment Requests to
Indicate a Health Insurance
Prospective Payment System
(HIPPS) Code Change - Rescinded
and replaced by Transmittal 1565
01/05/2009 	6002
R1472CP 	03/06/2008 	Update of Institutional Claims
References
04/07/2008 	5893
R1450CP 	02/15/2008 	Update to the Common Working File
(CWF) to Allow the Posting of
Skilled Nursing Facility (SNF) and
07/07/2008 	5872

Rev# 	Issue Date 	Subject 	Impl Date 	CR#
Swing Bed (SB) Claims to the
Beneficiary’s Spell of Illness When
Qualifying Stay Criteria are Not Met
R1421CP 	01/25/2008 	Update of Institutional Claims
References - Rescinded and
Replaced by Transmittal 1472
04/07/2008 	5893
R1394CP 	12/14/2007 	Manual Updates to Chapter 6,
Skilled Nursing Facility (SNF)
Inpatient Part A Billing for No
Payment and Medicare Advantage
(MA) Claims
03/17/2008 	5840
R1365CP 	11/02/2007 	Additional Common Working File
(CWF) Editing for Skilled Nursing
Facility (SNF) Consolidated Billing
(CB) – Part II
04/07/2008 	5757
R1355CP 	10/19/2007 	National Uniform Billing Committee
(NUBC) Update on Revenue Codes
and Corrected Skilled Nursing
Facility (SNF) Spell of Illness Chart
01/22/2008 	5734
R1290CP 	07/13/2007 	Clarification of Skilled Nursing
Facility (SNF) Billing Requirements
for Beneficiaries Enrolled in
Medicare Advantage (MA) Plans
01/07/2008 	5653
R1289CP 	07/13/2007 	Additional Common Working File
(CWF) Editing for Skilled Nursing
Facility (SNF) Consolidated Billing
(CB)
01/02/2008 	5624
R1252CP 	05/25/2007 	Clarification of Skilled Nursing
Facility (SNF) No Pay Billing
08/27/2007 	5583
R1151CP 	01/11/2007 	Skilled Nursing Facility (SNF)
Consolidated Billing (CB) Common
Working File (CWF) Edit Bypass
Instructions for Hospital Emergency
Room (ER) Services Spanning
Multiple Service Dates
04/02/2007 	5389
R1109CP 	11/09/2006 	Skilled Nursing Facility (SNF)
Consolidated Billing (CB) Common
04/02/2007 	5389

Rev# 	Issue Date 	Subject 	Impl Date 	CR#
Working File (CWF) Edit Bypass
Instructions for Hospital Emergency
Room (ER) Services Spanning
Multiple Service Dates
R1068CP 	09/27/2006 	2007 Annual Update of HCPCS
Codes for Skilled Nursing Facility
(SNF) Consolidated Billing (CB) for
the Common Working File (CWF),
Medicare Carriers and Fiscal
Intermediaries (FIs)
01/02/2007 	5283
R1009CP 	07/28/2006 	Correction to Skilled Nursing
Facility (SNF) Consolidated Billing
(CB) Enforcement if SNF Inpatient
Claims are Partially Non-Covered
01/02/2007 	5220
R980CP 	06/14/2006 	Changes Conforming to CR 3648
Instructions for Therapy Services -
Replaces Rev. 941
10/02/2006 	4014
R941CP 	05/05/2006 	Changes Conforming to CR 3648
Instructions for Therapy Services
10/02/2006 	4014
R930CP 	04/28/2006 	Benefits Exhaust and No-Payment
Billing Instructions for Medicare
Fiscal Intermediaries (FIs) and
Skilled Nursing Facilities (SNFs)
10/02/2006 	4292
R926CP 	04/28/2006 	Common Working File (CWF) File
Change for Skilled Nursing Facility
(SNF) Consolidated Billing (CB)
10/02/2006 	4390
R846CP 	02/10/2006 	New Skilled Nursing Facility
Consolidated Billing Web Site
Address
03/13/2006 	4297
R767CP 	12/02/2005 	SNF PPS Revisions to IOM 100-04-
Manualization
N/A 	4080
R740CP 	11/01/2005 	Change to the Common Working
File (CWF) Skilled Nursing Facility
(SNF) Consolidated Billing (CB)
Edits for Evaluation and
Management (E&M) Services Billed
04/03/2006 	3910

Rev# 	Issue Date 	Subject 	Impl Date 	CR#
to Fiscal Intermediaries (FIs) by
Hospitals
R696CP 	10/07/2005 	2006 Annual Update of HCPCS
Codes for Skilled Nursing Facility
(SNF) Consolidated Billing (CB) for
the Common Working File (CWF),
Medicare Carriers and Fiscal
Intermediaries (FIs)
01/03/2006 	4086
R685CP 	09/23/2005 	Discontinuation of the Skilled
Nursing Facility (SNF) HCPCS Help
File and Notification to Fiscal
Intermediaries (FIs) and Providers of
the Redesigned SNF Consolidated
Billing (CB) Annual Update File
Posted on CMS Web Site
12/27/2005 	4044
R630CP 	07/29/2005 	Medicare Part A Skilled Nursing
Facility (SNF) Prospective Payment
System (PPS) Pricer Update and
Health Insurance Prospective
Payment System (HIPPS) Coding
Update Effective January 1, 2006
01/03/2006 	3962
R540CP 	04/29/2005 	Addition to Chapter 6 of the Claims
Processing Manual - Skilled Nursing
Facility (SNF) Inpatient Part A
Billing: SNF Prospective Payment
System (PPS) Pricer Software
08/01/2005 	3774
R459CP 	02/04/2005 	Full Replacement of Change Request
(CR) 3427, Transmittal 342, Issued
on October 29, 2004- Change to the
Common Working File (CWF)
Skilled Nursing Facility (SNF)
Consolidated Billing (CB) Edits for
Ambulance Transports to or from a
Diagnostic or Therapeutic Site
04/05/2005 	3676
R437CP 	01/21/2005 	Revisions and Corrections to the
Medicare Claims Processing Manual,
Chapter 6, Section 30 and Various
Sections in Chapter 15
02/22/2005 	3664

Rev# 	Issue Date 	Subject 	Impl Date 	CR#
R429CP 	01/14/2005 	Change to the Common Working
File (CWF) Skilled Nursing Facility
(SNF) Consolidated Billing (CB)
Edits for Critical Access Hospitals
(CAHs) that have Elected Method II
Payment Option and Bill Physician
Services to their Fiscal
Intermediaries (FIs)
07/05/2005 	3561
R413CP 	12/23/2004 	Medicare Part A Skilled Nursing
Facility (SNF) Prospective Payment
System (PPS) Pricer Update FY 2005
for 9 Metropolitan Statistical Areas
(MSAs) with New Wage Index
Values Effective January 1, 2005
01/17/2005 	3651
R412CP 	12/23/2004 	Skilled Nursing Facility (SNF)
Consolidated Billing Service
Furnished under an "Arrangement"
with an Outside Entity
01/24/2005 	3592
R378CP 	11/26/2004 	Liability Days on Skilled Nursing
Facility (SNF) and Swing Bed
Facility Inpatient Bills
01/03/2005 	3568
R342CP 	10/29/2004 	Change to the Common Working
File (CWF) Skilled Nursing Facility
(SNF) Consolidated Billing (CB)
Edits for Ambulance Transports to or
from a Diagnostic or Therapeutic
Site
04/04/2005 	3427
R268CP 	07/30/2004 	Medicare Part A Skilled Nursing
Facility (SNF) Prospective Payment
System (PPS) Pricer Update FY 2005
10/04/2004 	3368
R253CP 	07/23/2004 	Fiscal Intermediary Shared System
(FISS) Changes to Allow for
Provider Liability Days on Skilled
Nursing Facility (SNF) and Swing
Bed Facility Inpatient Bills
01/03/2005 	3308
R229CP 	07/20/2004 	Additional Clarification of Bill
Types 22x and 23x Submitted by
Skilled Nursing Facilities (SNFs)
08/19/2004 	3323

Rev# 	Issue Date 	Subject 	Impl Date 	CR#
With Instructions for Involuntarily
Moving a Beneficiary Out of the
SNF and Ending a Benefit Period
R215CP 	06/25/2004 	Implementation of Skilled Nursing
Facility Consolidated Billing CWF
Edit for Therapy Codes Considered
Separately Payable Physician
Services
07/06/2004 	2944
R209CP 	06/18/2004 	Correction to CR 2944, Transmittal
90, Issued on February 6, 2004
07/06/2004 	3333
R200CP 	06/10/2004 	Update to the Common Working File
Edits for Skilled Nursing Facility
(SNF) Consolidated Billing (CB) to
Expand the Bypass for Pharmacy
Services.
10/04/2004 	3277
R183CP 	05/21/2004 	Skilled Nursing Facility (SNF)
Consolidated Billing: Services
Furnished Under an "Arrangement"
With an Outside Entity
07/01/2004 	3248
R163CP 	04/30/2004 	Change to the Common Working
File (CWF) Skilled Nursing Facility
(SNF) Consolidated Billing (CB)
Edits for Ambulance Transports to or
from a Diagnostic or Therapeutic
Site Other than a Physician's Office
or Hospital
10/04/2004 	3196
R133CP 	04/02/2004 	Billing NonCovered Charges to
Fiscal Intermediaries - Summary and
New Instructions - Clarification
04/16/2004 	3115
R094CP 	02/06/2004 	Additional Information in Medicare
Summary Notices (MSNs) to
Beneficiaries about Skilled Nursing
Facility (SNF) Benefits
07/06/2004 	3098
R092CP 	02/06/2004 	Updates to the January 2004 Annual
Update of HCPCS Codes Used for
Skilled Nursing Facility
Consolidated Billing Enforcement
04/05/2004 	3070

Rev# 	Issue Date 	Subject 	Impl Date 	CR#
R090CP 	02/06/2004 	Implementation of Skilled Nursing
Facility Consolidated Billing CWF
Edit for Therapy Codes Considered
Separately Payable Physician
Services
07/06/2004 	2944
R076CP 	02/06/2004 	SNF Inpatient Part A Billing 	N/A 	3133
R001CP 	10/01/2003 	Initial Publication of Manual 	NA 	NA
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