Medicare SNF Coverage Guidelines Under PPS

Under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS), coverage for SNF services includes post-hospital SNF services for which benefits are provided under Part A (the hospital insurance program) and all items and services that, before July 1, 1998, had been paid under Part B (the supplementary medical insurance program) but were furnished to SNF residents during a Part A covered stay. This coverage excludes:

• Physician services, physician assistant services, nurse practitioner and clinical nurse specialist services, certified mid-wife services, qualified psychologist services, certified registered nurse anesthetist services, certain dialysis-related services, erythropoietin (EPO) for certain dialysis patients, hospice care related to a terminal condition, ambulance trips that convey a beneficiary to the SNF for admission or from the SNF following discharge, ambulance transportation related to dialysis services, certain services involving chemotherapy and its administration, radioisotope services, certain customized prosthetic devices, certain blood clotting factors, and for services furnished during 1998 only, the transportation costs of electrocardiogram equipment for electrocardiogram test services.

Certain additional outpatient hospital services, along with ambulance transportation that conveys a beneficiary to a hospital or Critical Access Hospital (CAH) to receive the additional services, are excluded from coverage under SNF PPS and are billed separately. These additional services include:

• Cardiac catheterization services
• Computerized axial tomography (CT scans)
• Magnetic resonance imaging (MRIs)
• Radiation therapy
• Ambulatory surgery involving the use of a hospital operating room
• Emergency services
• Angiography services
• Lymphatic and venous procedures

The CMS identifies these services using HCPCS codes that are periodically updated, and publishes the HCPCS coding changes annually via a Recurring Update Notification. To view the online code list of exclusions from consolidated billing (the SNF “bundling” requirement), one can visit the CMS website.

This coverage guideline is crucial for ensuring that new nurses understand the scope of services covered under Medicare SNF PPS and the exclusions that apply, providing a clear framework for navigating Medicare billing and coverage issues in a SNF setting.