Respiratory care services furnished to a beneficiary residing in a Skilled Nursing Facility (SNF) will be included in the Part A stay. As such, these services are bundled in the facility's payment and are not separately billable. When a beneficiary is no longer eligible for Part A benefits (i.e., benefits exhausted), respiratory care services are not payable under Part B in the SNF setting and will be denied.

CMS provides clear guidance in the CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 7, section 10.1.1

• Directs the Standard System Maintainer (SSM) to prevent payment for SNF inpatient claims (Type of Bill (TOB) 22x) that include revenue code 041x (respiratory services)
• This edit reinforces that respiratory services are included in the SNF Part A bundled payment and are not payable separately

Additionally, CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 240.2 clarifies that when a beneficiary's Part A benefits are exhausted, claims submitted under TOB 012X that include revenue code 041X are not payable. In these scenarios, the services will be denied.

Noridian's Local Coverage Determination (LCD) - Respiratory Care (L34149) outlines the coverage of indications, limitations and medical necessity requirements. The associated Billing and Coding article (A57224) provides further direction on appropriate claim submission. The TOB 22x is not identified as a payable bill type for respiratory care services, consistent with CMS IOM requirements that services are bundled during a SNF Part A stay.

In limited situations involving A to B rebill, respiratory care services may be considered for Part B payment if all applicable criteria are met. However, if the beneficiaries of Part A benefits are exhausted, respiratory services will remain non-payable under Part B and will be denied.

Denial Information

When respiratory services are billed outside of Medicare coverage guidelines, the claim will be denied as a contractual obligation (non-covered charge).

• The denial will include remark code M28, which states:

"This does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise available."

This guidance reinforces the importance of understanding bundled payment rules and Medicare billing restrictions when providing respiratory care services in SNF and inpatient settings.