Skilled Nursing Facility (SNF) Billing Guide

Skilled Nursing Facility (SNF) Residents

CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 20, §211 Section 4432(b) of the Balanced Budget Act (BBA) requires Consolidated Billing (CB) for the SNF. The CB requirement essentially confers on the SNF itself the Medicare billing responsibility for the entire package of care that its residents receive, except for a limited number of specifically excluded services.

For services and supplies furnished to a SNF resident covered under the Part A benefit, SNFs are not able to unbundle services to an outside provider of services or supplies that can then submit a separate bill directly to the Medicare Contractor. Instead, the SNF must furnish the services or supplies either directly or under an arrangement with an outside provider. The SNF, rather than the provider of the service or supplies, bills Medicare. Medicare does not pay amounts that are due a provider of the services or supplies to any other entity under assignment, power of attorney, or any other direct payment arrangement (See 42 CFR 424.73.). As a result, if you have supplied an item or service to a beneficiary who is a resident in a covered Part A stay, you must look to the SNF, rather than to the beneficiary or the DME MAC, for payment. The SNF may collect any applicable deductible or coinsurance from the beneficiary. Most covered services and supplies billed by the SNF, including those furnished under arrangement with an outside provider, for a resident of a SNF in a covered Part A stay are included in the SNF’s bill to the Fiscal Intermediary (FI).

It is your responsibility to check with the facility to see if your patient is a resident in a covered Part A stay. If so, all services must be billed to Medicare by the SNF except for certain excluded items. A complete list of these excluded items (listed by HCPCS code) may be found on the CMS website at If a HCPCS code appears on this list, then it may be billed to the DME MAC for payment, even if the beneficiary is in a covered Part A SNF stay. Note: in order to access the list, click on the link above, select the appropriate “FI/A/B MAC Update” (whichever year in which the service took place), and then open the ZIP file found in the Downloads section.

Item 20 – Leave blank. Not required by the DME MAC.
Item 21 – Enter the patient's diagnosis/condition. You must use an ICD-10 code number and code to the highest level of specificity for the date of service. Enter up to 12 diagnoses in priority order. All narrative diagnoses for non-physician specialties must be submitted on an attachment.
Item 21 ICD Ind. – Enter “0” or leave blank. Currently not required by Medicare.
Item 22 – Leave blank. Not required by Medicare.
Item 23 – Leave blank. Not required by the DME MAC.
Item 24 – The six service lines in section 24 have been divided horizontally to accommodate submission of supplemental information to support the billed service. The top portion in each of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 service lines.

The following providers of service/suppliers and claims can only be paid on an assignment basis (the services applicable to DME MAC are bolded):

• Clinical diagnostic laboratory services;
• Physician services to individuals dually entitled to Medicare and Medicaid;
• Participating physician/supplier services;
• Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, and clinical social workers;
• Ambulatory surgical center services for covered ASC procedures;
• Ambulance services;
• Drugs and biologicals; and
• Simplified Billing Roster for influenza virus vaccine and pneumococcal vaccine.
Item 28 – Enter total charges for the services (i.e., total of all charges in item 24f).
Item 29 – Enter the total amount the patient paid on the covered services only.

NOTE: This field may/will affect payment if assignment was accepted.
Item 30 – Leave blank. Not required by Medicare.
Item 31 – Enter your signature (or that of your authorized representative) and either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alphanumeric date (e.g., January 1, 1998) the form was signed.

For foreign claims, only the enrollee can file for Part B benefits rendered outside of the United States.
Item 32a – If required by Medicare claims processing policy, enter the NPI of the service facility
Item 32b – Effective May 23, 2008, Item 32b is not to be reported
Item 33 – Enter your billing name, address, ZIP code, and telephone number. This is a required field.
Item 33a – Enter your NPI. This is a required field.
Item 33b – Effective May 23, 2008, Item 33b is not to be reported (unless billed via Indirect Payment Procedure (IPP); if you are an IPP biller, please follow IPP billing guidelines).

The rules below apply to both assigned and unassigned claims.

To fulfill the signature requirement of item 31 of the Form CMS-1500, you may:

a) Sign item 31 of Form CMS-1500.

b) Sign a one time certification letter for machine-prepared claims submitted on other than paper vehicles.

c) Authorize an employee (e.g., nurse, administrative assistant) to enter the supplier signature in item 31 of the Form CMS-1500 (manually, by stamp-facsimile or block letters, or by computer).

d) Authorize a non-employee agent (e.g., billing service or association) to enter the supplier signature in item 31 of the Form CMS-1500, followed by the agent’s name, title, and organization (e.g., a billing agent might enter by stamp “Dr. Tom Jones by Robert Smith, Secretary, Ajax Billing Service”). Alternatively, the agent may simply enter the supplier signature.

SNF Consolidated Billing - Capped Rental DME

CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 20, §211 Medicare pays for durable medical equipment (DME) when it is medically necessary for use in a beneficiary’s home.

For capped rental items of DME in which you submit a monthly bill, the date of delivery on the first claim must be the “from” or anniversary date on all subsequent claims for the item.

The DME benefit is only meant for items a beneficiary is using in his or her home. For a beneficiary in a Part A stay, a SNF is not defined as a beneficiary’s home. Medicare does not make separate payment for DME when a beneficiary is in a SNF. The SNF is expected to provide all medically necessary DMEPOS during a beneficiary’s covered Part A stay. However, in accordance with DMEPOS payment policy, Medicare will make a separate payment for a full month of rental for DME items, provided the beneficiary was in the home on the “from” date or anniversary date defined above. Medicare will make payment for the entire month, even if the “from” date is the date of discharge from the SNF.

If a beneficiary using DME is in a covered Part A stay in a SNF for a full month, Medicare will not make payment for the DME for that month. If the beneficiary is in a Part A covered stay, but not for the entire month, the discharge date becomes the new anniversary date for subsequent claims. In this situation, you must submit a new claim using the date of discharge as the “from” date. You should note in the NTE segment/line note (field 19 for paper claims) that the beneficiary was in a SNF, resulting in the need to establish a new
anniversary date.

The Balanced Budget Act of 1997 requires consolidated billing of all home health services while a beneficiary is under a home health plan of care authorized by a physician (referred to as a “home health episode”). Consequently, billing for all such items and services will be made to a single home health agency (HHA) overseeing that plan.

The law states that payment will be made to the primary HHA whether or not the item or service was furnished by the agency, by others under arrangement to the primary agency, or when any other contracting or consulting arrangements existed with the primary agency, or “otherwise.” Payment for all items is scheduled in the home health PPS episode payment that the primary HHA receives.

Types of services that are subject to the home health consolidated billing provision include:

• Skilled nursing care;
• Home health aide services;
• Physical therapy;
• Speech-language pathology;
• Occupational therapy;
• Medical social services;
• Routine and non-routine medical supplies (see below);
• Medical services provided by an intern or resident-in-training of a hospital, under an approved teaching program of the hospital, in the case of a HHA that is affiliated or under common control with that hospital; and

• Care for homebound patients involving equipment too cumbersome to take to the home.  Routine and Non-Routine Medical Supplies When a beneficiary is in a 60-day home health episode, these items are included in the PPS episode payment. HHAs must bill for all supplies provided during the 60-day episode, including those not related to the Plan of Care, because of the consolidated billing requirements.

The “Home Health Consolidated Billing Master Code List” is a list of the HCPCS codes which apply to home health consolidated billing. It is available on the CMS website at If a HCPCS code appears on this list, it may not be billed to the DME MAC when the beneficiary is in a home health episode.

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