Part A Information

MLN Matters Number: MM5991
Related Change Request (CR) #: 5991
Related CR Release Date: May 16, 2008
Effective Date: June 16, 2008
Related CR Transmittal #: R89BP
Implementation Date: June 16, 2008

Medical and Other Health Services Furnished to SNF Patients

Provider Types Affected
Skilled nursing facilities (SNF) submitting claims to Medicare contractors (fiscal intermediaries (FI) and/or Part A/B Medicare administrative contractors (A/B MAC)) for Part B services, including outpatient therapy services provided to Medicare beneficiaries

Provider Action Needed
This article is based on Change Request (CR) 5991 which revises the Medicare Benefit Policy Manual (Chapter 8, Section 70) to clarify coverage of Part B services paid in SNFs, including outpatient physical therapy services, outpatient occupational therapy services, and outpatient speech pathology services.

Background
The Social Security Act (Section 1861) provides for the coverage of medical and other health services that are paid through Medicare Part B, including the provision of outpatient physical therapy services and outpatient occupational therapy services. You can review Section 1861 of the Social Security Act at http://www.ssa.gov/OP_Home/ssact/title18/1861.htm on the Internet.

With CR 5991, the Centers for Medicare & Medicaid Services (CMS) is making a slight modification to Section 70, Chapter 8 of the Medicare Benefit Policy Manual. Previously, that section of the manual began with the following paragraph:

“The medical and other health services listed below and described in the Medicare Benefit Policy Manual, Chapter 6, “Hospital Services Covered Under Part B,” Section 10, are covered under Part B when furnished by a participating SNF either directly or under arrangements to: inpatients who are not entitled to have payment made under Part A (e.g., benefits exhausted or three-day prior-stay requirement not met); or outpatients.” (Emphasis added on “or outpatients.”)

To avoid confusion, CMS is deleting the words “or outpatients” from the end of that quoted paragraph. That is the key change that CR5991 makes, as none of the other services listed in this section of the manual can be provided by an SNF on an outpatient basis other than physical and occupational therapy and speech pathology services.

Outpatient physical and occupational therapy and outpatient speech pathology services may be provided by a SNF to its “outpatients,” including:

• Those of its own patients in their homes,
• Patients who come to the SNF’s outpatient department,
• Inpatients of other institutions, and
• The SNFs own inpatients who have exhausted their Part A benefits or who are not otherwise eligible for Part A benefits.

In addition, CR5991 reminds SNFs of the following existing policies:

• SNFs may furnish physical therapy, occupational therapy, or speech language pathology services to their inpatients without having to set up facilities and procedures for furnishing the same services to outpatients. However, if the SNF chooses to furnish the therapy services mentioned in this article, the SNF must bill the program under Part B and may only charge the patient for the applicable deductible and coinsurance.
• In the case of a distinct part SNF, the certified part must bill the program under Part B for any outpatient physical therapy, occupational therapy, or speech language pathology services that the certified distinct part itself furnishes to inpatients of the noncertified part.
• Alternatively, residents of the noncertified part can receive outpatient therapy services from a hospital that exceed the Part B therapy caps, in accordance with CR 2674 (Program Memorandum A-03-040, May 9, 2003) which can be found at http://www.cms.hhs.gov/Transmittals/downloads/A03040.pdf on the CMS Web site.

Additional Information
The official instruction, CR 5991, issued to your FI or A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R89BP.pdf on the CMS Web site.

If you have any questions, please contact your FI or A/B MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.