Medicare Quantity Limits for SNF Part B Supplies: The 3 Numbers to Check Before You Bill
Eric HansenFounder, Burst BillingOctober 5, 20268 min readMedicare limits SNF Part B supply quantities in 2 ways. Coverage policies list a usual maximum for each code, and a claim can go over it when the chart says why. The claims system also runs medically unlikely edits, or MUEs, that deny a line over a set number of units in a day. Neither number is an allowance. The right quantity is what the practitioner ordered and the resident used, with the chart to prove it.
A usual maximum is your mother saying "be home by 10." You can come home at midnight. You'd better have a note.
An MUE is the deadbolt. It doesn't read notes. (You can still knock. Medicare calls that an appeal.)
And "home by 10" was never an order to stay out until 10.
Mix those up and you get both kinds of quantity trouble: claims that deny, and claims that pay less than the chart supports.
The usual maximum
Each supply category has a Local Coverage Determination, or LCD. The LCD lists the most units of each code that are "usually reasonable and necessary."
Read the next line in the tracheostomy LCD. The quantity a resident needs "may be more or less than the amount listed."
Going over has a price. The explanation "must be clearly documented in the beneficiary's medical record." Without it, the extra units deny as not reasonable and necessary.
So an order above the usual maximum is billable when the chart says why this resident needs more.
The MUE
An MUE is a number built into the claims system. CMS defines it as the most units "you would report under most circumstances for a single patient on a single date of service." Bill more than that, and the line denies.
4 things to know about it:
- You can appeal. CMS says a MAC may pay units over the MUE when the documentation shows medical necessity.
- You can't bill the resident for units denied on an MUE. An ABN doesn't change that.
- Some codes have no MUE.
- CMS keeps some MUE values confidential.
The 3 numbers
Before a claim goes out, put 3 numbers side by side.
The order. What the treating practitioner ordered: the item, and the quantity or frequency.
The usage. What the chart shows the resident used.
The limit. The usual maximum for the code, and the MUE if the code has one.
Then work down this list:
- Usage at or under the order, and under the limit. Bill the usage.
- Usage under the order. Bill the usage. The order gives permission, and the chart supplies the count.
- Usage over the order. Get the order updated before you bill.
- Usage over the usual maximum. Find the reason in the chart. If it's there, bill the usage. If it's missing, get it written before the claim goes out.
- Usage over the MUE. The line will deny. Appeal it with the chart.
All of this starts after Part A. During a covered Part A stay, the per diem pays for the supplies and there is no Part B quantity to check.
What the limits look like in each category
Surgical dressings
LCD L33831. The limit is a change frequency, set by dressing type:
- Foam, hydrocolloid, and transparent film: up to 3 times a week.
- Alginate: once a day.
- Contact layer: once a week.
- Gauze without a border: up to 3 times a day.
The code also depends on the size of the dressing, and the dressing has to fit the wound. That makes the wound measurement part of the math. For a nursing facility resident, the wound gets evaluated weekly. And a month's supply is the most that goes out at one time.
Ostomy supplies
LCD L33828. The limit is a monthly count, set by pouch type:
- Drainable pouches: 20 a month for most codes.
- Closed pouches: 60 a month.
- Urostomy pouches: 20 a month.
Put a closed-pouch quantity on a drainable-pouch code and the claim is 40 over before lunch.
Urological supplies
LCD L33803. The limit depends on the catheter:
- Indwelling catheter: 1 a month. The DME MACs name the reasons for another one: it came out by accident, it malfunctioned, or it's obstructed.
- Intermittent catheters: up to 200 a month.
Tracheostomy supplies
LCD L33832. A tube pays 1 every 3 months. The care kit for an established trach pays 31 a month. Suction catheters aren't on the list. Medicare treats them as supplies for a suction pump, and it doesn't pay for that equipment inside a SNF.
Splints and orthoses
These carry no monthly count. Each brace has a reasonable useful lifetime. Bill an identical knee brace for the same knee inside that window and the claim denies.
Ask your MAC 2 questions
A caution before you tape those numbers to the wall.
The DME MACs wrote those LCDs. A SNF's Part B supply claim goes to an A/B MAC on a 22X bill. And CMS's guide lists the outpatient facility MUE file for bill types 13X, 14X, 85X, and 087X. 22X isn't named.
So ask your MAC:
- Do you apply the DME MAC usual maximums to 22X supply claims?
- Which MUE file runs against them?
I can't answer those for your building from here. Your MAC can, in writing.
2 ways to get the quantity wrong
Over. The quantity came from a shipping record. A shipping record shows what left the warehouse. The chart shows what touched the resident. When the claim follows the box count and the box count runs past the limit, the extra units deny, or they pay and wait for an audit.
Under. The team doesn't know the number, so it bills low to stay safe. The chart shows 150 intermittent catheters used. The claim says 90. Medicare pays for 90. The claim never denies, so the gap never shows up on a report.
One billing office can do both in the same month: over on dressings, under on catheters.
The fix is the same for both. Start from the chart, and check it against the order and the limit.
Who runs the check
Burst does the billing. Before every claim, we check the quantity against the order, the usage your clinical team documented in PointClickCare, and the limit for that code. A person reviews every claim before it goes out.
When a quantity runs over a limit, we ask your team for the documentation that supports it before the claim goes out. When the chart supports more than was first counted, the claim goes out at what the chart supports.
We've processed 18,974 claims across 16 states. You pay only when a claim pays. Setup costs $0, the monthly minimum is $0, and the agreement runs month to month.
Run the check on last month
Sources
- CMS MLN, How to Use the Medicare National Correct Coding Initiative (NCCI) Tools
- LCD L33832, Tracheostomy Care Supplies
- LCD L33831, Surgical Dressings
- Noridian DME MAC, ordering surgical dressings
- Noridian DME MAC, ordering urological supplies
- CMS provider compliance tips: ostomy supplies
- CMS provider compliance tips: suction pumps
- CMS RAC topic 0148, same knee orthosis within reasonable useful lifetime
- Medicare Claims Processing Manual, Chapter 7, SNF Part B billing
- CMS, SNF Consolidated Billing
Written by
Eric Hansen
Founder, Burst Billing
Eric Hansen is the founder of Burst Billing, with 15 years in long-term care across both the provider and vendor sides. He helps skilled nursing facilities recover missed Medicare Part B supply reimbursement through cleaner documentation, tighter vendor workflows, and contingency-based billing reviews.
More from Eric →Frequently asked questions
- Medicare uses 2 controls. Local Coverage Determinations list a usual maximum quantity for each supply code, and a claim can exceed it when the medical record documents why the resident needs more. Medically unlikely edits (MUEs) are per-day unit limits built into the claims system, and a line over the MUE denies. Neither number is an allowance. The claim quantity is what was ordered, used, and documented.
- Under LCD L33831, the limit is a change frequency set by dressing type. Foam, hydrocolloid, and transparent film dressings are covered up to 3 times a week, alginate once a day, and contact layers once a week. The code depends on dressing size, and the dressing must fit the wound, so the claim needs a current wound measurement. For a nursing facility resident, the wound is evaluated weekly, and no more than a month's supply goes out at one time.
- The DME MAC coverage policy for urological supplies lists up to 200 intermittent catheters a month, and the medical record must support the quantity ordered. An indwelling catheter is covered at 1 a month, with more for accidental removal, malfunction, or obstruction. Bill the number the resident used, as the chart documents it.
- It depends on the limit. Units over an LCD usual maximum are covered when the medical record explains the need, and they deny as not reasonable and necessary when it doesn't. Units over an MUE deny on the claim line. CMS allows a MAC to pay units over the MUE on appeal when the documentation shows medical necessity. A facility can't bill the resident for units denied on an MUE.
- Under-claiming is billing fewer units than the resident used and the chart documents. It happens when a billing team doesn't know the limit for a code and bills low to avoid a denial. The claim pays, so the shortfall produces no denial and appears on no report.
- Ask your MAC. The DME MACs wrote the LCDs that list usual maximum quantities, and a SNF's Part B supply claim goes to an A/B MAC on a 22X bill. CMS's guide lists the outpatient facility MUE file for bill types 13X, 14X, 85X, and 087X and does not name 22X. Get your MAC's answer in writing.
- 3 numbers for every line: the quantity the treating practitioner ordered, the quantity the chart shows the resident used, and the limit for the code. Bill the usage. If the usage runs over the order, update the order first. If it runs over the usual maximum, confirm the chart documents the reason.
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