Medicare Benefit Policy Manual
Chapter 15 – Covered Medical and Other Health Services
Table of Contents
(Rev. 12684; Issued: 06-13-24)
Transmittals for Chapter 15
10 - Supplementary Medical Insurance (SMI) Provisions
20 - When Part B Expenses Are Incurred
20.1 - Physician Expense for Surgery, Childbirth, and Treatment for Infertility
20.2 - Physician Expense for Allergy Treatment
20.3 - Artificial Limbs, Braces, and Other Custom Made Items Ordered But Not Furnished
30 - Physician Services
30.1 - Provider-Based Physician Services
30.2 - Teaching Physician Services
30.3 - Interns and Residents
30.4 - Optometrist’s Services
30.5 - Chiropractor’s Services
30.6 - Indian Health Service (IHS) Physician and Nonphysician Services
30.6.1 - Payment for Medicare Part B Services Furnished by Certain IHS Hospitals and
Clinics
40 - Effect of Beneficiary Agreements Not to Use Medicare Coverage
40.1 - Private Contracts Between Beneficiaries and Physicians/Practitioners
40.2 - General Rules of Private Contracts
40.3 - Effective Date of the Opt-Out Provision
40.4 - Definition of Physician/Practitioner
40.5 - When a Physician or Practitioner Opts Out of Medicare
40.6 - When Payment May be Made to a Beneficiary for Service of an Opt-Out Physician/Practitioner
40.7 - Definition of a Private Contract
40.8 - Requirements of a Private Contract
40.9 - Requirements of the Opt-Out Affidavit
40.10 - Failure to Properly Opt Out
40.11 - Failure to Maintain Opt-Out
40.12 - Actions to Take in Cases of Failure to Maintain Opt-Out
40.13 - Physician/Practitioner Who Has Never Enrolled in Medicare
40.14 - Nonparticipating Physicians or Practitioners Who Opt Out of Medicare
40.15 - Excluded Physicians and Practitioners
40.16 - Relationship Between Opt-Out and Medicare Participation Agreements
40.17 - Participating Physicians and Practitioners
40.18 - Physicians or Practitioners Who Choose to Opt Out of Medicare
40.19 - Opt-Out Relationship to Noncovered Services
40.20 - Maintaining Information on Opt-Out Physicians
40.21 - Informing Medicare Managed Care Plans of the Identity of the Opt-Out Physicians or
Practitioners
40.22 - Informing the National Supplier Clearinghouse (NSC) of the Identity of the Opt-Out
Physicians or Practitioners
40.23 - Organizations That Furnish Physician or Practitioner Services
40.24 - The Difference Between Advance Beneficiary Notices (ABN) and Private Contracts
40.25 - Private Contracting Rules When Medicare is the Secondary Payer
40.26 - Registration and Identification of Physicians or Practitioners Who Opt Out
40.27 - System Identification
40.28 - Emergency and Urgent Care Situations
40.29 - Definition of Emergency and Urgent Care Situations
40.30 - Denial of Payment to Employers of Opt-Out Physicians and Practitioners
40.31 - Denial of Payment to Beneficiaries and Others
40.32 - Payment for Medically Necessary Services Ordered or Prescribed by an Opt-out physician or
Practitioner
40.33 - Mandatory Claims Submission
40.34 - Cancellation of Opt-Out
40.35 - Early Termination of Opt-Out
40.36 - Appeals
40.37 - Application to the Medicare Advantage Program
40.38 - Claims Denial Notices to Opt-Out Physicians and Practitioners
40.39 - Claims Denial Notices to Beneficiaries
50 - Drugs and Biologicals
50.1 - Definition of Drug or Biological
50.2 - Determining Self-Administration of Drug or Biological
50.3 - Incident-to Requirements
50.4 - Reasonableness and Necessity
50.4.1 - Approved Use of Drug
50.4.2 - Unlabeled Use of Drug
50.4.3 - Examples of Not Reasonable and Necessary
50.4.4 - Payment for Antigens and Immunizations
50.4.4.1 - Antigens
50.4.4.2 - Immunizations
50.4.5 - Off Lable Use of Anti-Cancer Drugs and Biologicals
50.4.5.1 - Process for Amending the List of Compendia for Determination of
Medically-Accepted Indications for Off-Label Uses of Drugs and Biologicals in an
Anti-Cancer Chemotherapeutic Regimen
50.4.6 - Less Than Effective Drug
50.4.7 - Denial of Medicare Payment for Compounded Drugs Produced in Violation of
Federal Food, Drug, and Cosmetic Act
50.4.8 - Process for Amending the List of Compendia for Determination of Medically-
Accepted Indications for Off-Label Uses of Drugs and Biologicals in an Anti-Cancer
Chemotherapeutic Regimen
50.5 - Self-Administered Drugs and Biologicals
50.5.1 - Immunosuppressive Drugs
50.5.2 - Erythropoietin (EPO)
50.5.2.1 - Requirements for Medicare Coverage for EPO
50.5.2.2 - Medicare Coverage of Epoetin Alfa (Procrit) for Preoperative Use
50.5.3 - Oral Anti-Cancer Drugs
50.5.4 - Oral Anti-Nausea (Anti-Emetic) Drugs
50.5.5 - Hemophilia Clotting Factors
50.6 - Coverage of Intravenous Immune Globulin for Treatment of Primary Immune Deficiency
Diseases in the Home
60 - Services and Supplies Furnished Incident To a Physician's/NPP's Professional Service
60.1 - Incident To Physician’s Professional Services
60.2 - Services of Nonphysician Personnel Furnished Incident To Physician’s Services
60.3 - Incident To Physician’sServices in Clinic
60.4 - Services Incident to a Physician’s Service to Homebound Patients Under General Physician
Supervision
60.4.1 - Definition of Homebound Patient Under the Medicare Home Health (HH) Benefit
70 - Sleep Disorder Clinics
80 - Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
80.1 - Clinical Laboratory Services
80.1.1 - Certification Changes
80.1.2 - A/B MAC (B) Contacts With Independent Clinical Laboratories
80.1.3 - Independent Laboratory Service to a Patient in the Patient’s Home or an Institution
80.2 - Psychological and Neuropsychological Tests
80.3 - Audiology Services
80.3.1 - Definition of Qualified Audiologist
80.4 - Coverage of Portable X-Ray Services Not Under the Direct Supervision of a Physician
80.4.1 - Diagnostic X-Ray Tests
80.4.2 - Applicability of Health and Safety Standards
80.4.3 - Scope of Portable X-Ray Benefit
80.4.4 - Exclusions From Coverage as Portable X-Ray Services
80.4.5 - Electrocardiograms
80.5 - Bone Mass Measurements (BMMs)
80.5.1 - Background
80.5.2 - Authority
80.5.3 - Definition
80.5.4 - Conditions for Coverage
80.5.5 - Frequency Standards
80.5.6 - Beneficiaries Who May be Covered
80.5.7 - Noncovered BMMs
80.5.8 - Claims Processing
80.5.9 - National Coverage Determinations (NCDs)
80.6 - Requirements for Ordering and Following Orders for Diagnostic Tests
80.6.1 - Definitions
80.6.2 - Interpreting Physician Determines a Different Diagnostic Test is Appropriate
80.6.3 - Rules for Testing Facility to Furnish Additional Tests
80.6.4 - Rules for Testing Facility Interpreting Physician to Furnish Different or Additional
Tests
80.6.5 - Surgical/Cytopathology Exception
90 - X-Ray, Radium, and Radioactive Isotope Therapy
100 - Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and
Dislocations
110 - Durable Medical Equipment - General
110.1 - Definition of Durable Medical Equipment
110.2 - Repairs, Maintenance, Replacement, and Delivery
110.3 - Coverage of Supplies and Accessories
110.4 - Miscellaneous Issues Included in the Coverage of Equipment
110.5 - Incurred Expense Dates for Durable Medical Equipment
110.6 - Determining Months for Which Periodic Payments May Be Made for Equipment Used in an
Institution
110.7 - No Payment for Purchased Equipment Delivered Outside the United States or Before
Beneficiary’s Coverage Began
110.8 – DMEPOS Benefit Category Determinations
120 - Prosthetic Devices
130 - Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes
140 - Therapeutic Shoes for Individuals with Diabetes
145 Lymphedema Compression Treatment Items
150 - Dental Services
150.1 - Treatment of Temporomandibular Joint (TMJ) Syndrome
160 - Clinical Psychologist Services
170 - Clinical Social Worker (CSW) Services
180 - Nurse-Midwife (CNM) Services
190 - Physician Assistant (PA) Services
200 - Nurse Practitioner (NP) Services
210 - Clinical Nurse Specialist (CNS) Services
220 - Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy,
and Speech-Language Pathology Services) Under Medical Insurance
220.1 - Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy,
or Speech-Language Pathology Services
220.1.1 - Care of a Physician/Nonphysician Practitioner (NPP)
220.1.2 - Plans of Care for Outpatient Physical Therapy, Occupational Therapy, or Speech-
Language Pathology Services
220.1.3 - Certification and Recertification of Need for Treatment and Therapy Plans of Care
220.1.4 - Requirement That Services Be Furnished on an Outpatient Basis
220.2 - Reasonable and Necessary Outpatient Rehabilitation Therapy Services
220.3 - Documentation Requirements for Therapy Services
220.4 - Functional Reporting
230 - Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology
230.1 - Practice of Physical Therapy
230.2 - Practice of Occupational Therapy
230.3 - Practice of Speech-Language Pathology
230.4 - Services Furnished by a Therapist in Private Practice (TPP)
230.5 - Physical Therapy, Occupational Therapy and Speech-Language Pathology Services Provided
Incident to the Services of Physicians and Nonphysician Practitioners (NPP)
230.6 - Therapy Services Furnished Under Arrangements With Providers and Clinics
231 - Pulmonary Rehabilitation (PR) Program Services Effective For Dates of Service On Or After January
1, 2024
232 - Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Services
Effective For Dates of Service On Or After January 1, 2024
240 - Chiropractic Services - General
240.1 - Coverage of Chiropractic Services
240.1.1 - Manual Manipulation
240.1.2 - Subluxation May Be Demonstrated by X-Ray or Physician’s Exam
240.1.3 - Necessity for Treatment
240.1.4 – Location of Subluxation
240.1.5 - Treatment Parameters
250 - Medical and Other Health Services Furnished to Inpatients of Hospitals and Skilled Nursing Facilities
260 - Ambulatory Surgical Center Services
260.1 - Definition of Ambulatory Surgical Center (ASC)
260.2 - Ambulatory Surgical Center Services
260.3 - Services Furnished in ASCs Which are Not ASC Facility Services
260.4 - Coverage of Services in ASCs, Which are Not ASC Services
260.5 - List of Covered Ambulatory Surgical Center Procedures
260.5.1 - Nature and Applicability of ASC List
260.5.2 - Nomenclature and Organization of the List
260.5.3 - Rebundling of CPT Codes
270 - Telehealth Services
280 – Preventive and Screening Services
280.1 – Glaucoma Screening
280.2 - Colorectal Cancer Screening
280.2.1 - Covered Services and HCPCS Codes
280.2.2 - Coverage Criteria
280.2.3 - Determining Whether or Not the Beneficiary is at High Risk for Developing
Colorectal Cancer
280.2.4 - Determining Frequency Standards
280.2.5 - Noncovered Services
280.3 - Screening Mammography
280.4 - Screening Pap Smears
280.5 - Annual Wellness Visit (AWV) Providing Personalized Prevention Plan Services (PPPS)
280.5.1 – Advance Care Planning (ACP) Furnished as an Optional Element with an Annual
Wellness Visit (AWV) upon Agreement with the Patient
290 - Foot Care
300 - Diabetes Self-Management Training Services
300.1 - Beneficiaries Eligible for Coverage and Definition of Diabetes
300.2 - Certified Providers
300.3 - Frequency of Training
300.4 - Coverage Requirements for Individual Training
300.4.1- Incident -To Provision
300.5 - Payment for DSMT
300.5.1 - Special Claims Processing Instructions A/B MACs (A)
310 – Kidney Disease Patient Education Services
310.1 - Beneficiaries Eligible for Coverage
310.2 - Qualified Person
310.3 - Limitations for Coverage
310.4 - Standards for Content
310.5 - Outcomes Assessment
320 – Home Infusion Therapy Services
320.1 – General Requirements for Payment of Home Infusion Therapy Services
320.2 – Home Infusion Therapy Services Benefit is Separate from DME Benefit
320.3 – Qualified Home Infusion Therapy Suppliers
320.4 – Patient Eligibility for Home Infusion Therapy
320.4.1 - Home Infusion Therapy Services for Homebound Patients
320.5 – Plan of Care Requirements
320.5.1 - Notification of Available Infusion Therapy Options
320.5.2 - Plan of Care Periodic Review and Provider Coordination
320.6 – Professional Services, Including Nursing Services, for Home Infusion
Therapy
320.6.1 - Home Infusion Therapy Services Training and Education
320.6.2 - Remote Monitoring and Monitoring Services
320.7 – Home Infusion Therapy Drugs
320.7.1 - Determining Qualifying Home Infusion Drugs
320.8 – Determining Qualifying Home Infusion Drugs
320.8.1 - Home Infusion Drug Payment Categories
320.8.2 - Infusion Drug Administration Calendar Day and Unit of Single Payment
320.8.3 - Initial Visits and Subsequent Visits for Home Infusion Therapy Services
320.9– Medical Review
330- Marriage and Family Therapist (MFT) Services
340- Mental Health Counselor (MHC) Services
10 - Supplementary Medical Insurance (SMI) Provisions
(Rev. 11355; Issued:04-14-22; Effective: 05-16-22; Implementation: 05-16-22)
The supplementary medical insurance plan covers expenses incurred for the following medical and other
health services under Part B of Medicare:
• Physician’s services, including surgery, consultation, office and institutional calls, and services and
supplies furnished incident to a physician’s professional service;
• Outpatient hospital services furnished incident to physicians services;
• Outpatient diagnostic services furnished by a hospital;
• Outpatient physical therapy, outpatient occupational therapy, outpatient speech-language pathology
services;
• Diagnostic x-ray tests, laboratory tests, and other diagnostic tests;
• X-ray, radium, and radioactive isotope therapy;
• Surgical dressings, and splints, casts, and other devices used for reduction of fractures and
dislocations;
• Rental or purchase of durable medical equipment for use in the patient’s home;
• Ambulance service;
• Prosthetic devices, other than dental, which replace all or part of an internal body organ;
• Leg, arm, back and neck braces and artificial legs, arms, and eyes including adjustments, repairs,
and replacements required because of breakage, wear, loss, or change in the patient’s physical
condition;
• Certain medical supplies used in connection with home dialysis delivery systems;
• Rural health clinic (RHC) services;
• Federally Qualified Health Center (FQHC) services;
• Ambulatory surgical center (ASC) services;
• Screening mammography services;
• Screening pap smears and pelvic exams;
• Screening glaucoma services;
• Influenza, pneumococcal pneumonia, hepatitis B, and COVID-19 vaccines;
• Colorectal screening;
• Bone mass measurements;
• Diabetes self-management services;
• Prostate screening; and
• Home health visits after all covered Part A visits have been used.
See §250 for provisions regarding supplementary medical insurance coverage of certain of these services
when furnished to hospital and SNF inpatients.
Payment may not be made under Part B for services furnished an individual if the individual is entitled to
have payment made for those services under Part A. An individual is considered entitled to have payment
made under Part A if the expenses incurred were used to satisfy a Part A deductible or coinsurance amount,
or if payment would be made under Part A except for the lack of a request for payment or lack of a
physician certification.
Some medical services may be considered for coverage under more than one of the above-enumerated
categories. For example, electrocardiograms (EKGs) can be covered as physician’s services or as other
diagnostic tests. It is sufficient to determine that the requirements for coverage under one category are met
to permit payment.
Membership dues, subscription fees, charges for service policies, insurance premiums, and other payments
analogous to premiums which entitle enrollees to services or to repairs or replacement of devices or
equipment or parts thereof without charge or at a reduced charge, are not considered expenses incurred for
covered items or services furnished under such contracts or undertakings. Examples of such arrangements
are memberships in ambulance companies, insurance for replacement of prosthetic lenses, and service
contracts for durable medical equipment.
20 - When Part B Expenses Are Incurred
(Rev. 1, 10-01-03)
B3-2005
Part B expenses for items and services other than expenses for surgery and childbirth (see §20.1, below), are
considered to have been incurred on the date the beneficiary received the item or service, regardless of when
it was paid for or ordered. Therefore, when an individual orders an item prior to his or her entitlement to
supplemental medical insurance (SMI) but receives the item after the effective date of SMI enrollment, the
expense is considered incurred after entitlement began. However, if an item not custom-made for the
beneficiary was ordered but not furnished, no reimbursement can be made. (See §20.3 for rules concerning
custom-made items ordered but not furnished and the Medicare Claims Processing Manual, Chapter 20,
“Durable Medical Equipment, Prosthetics and Orthotics, and Supplies (DMEPOS),” for additional rules
concerning the date of incurred expenses for durable medical equipment.)
20.1 - Physician Expense for Surgery, Childbirth, and Treatment for Infertility
(Rev. 1, 10-01-03)
B3-2005.l
A. Surgery and Childbirth
Skilled medical management is covered throughout the events of pregnancy, beginning with diagnosis,
continuing through delivery and ending after the necessary postnatal care. Similarly, in the event of
termination of pregnancy, regardless of whether terminated spontaneously or for therapeutic reasons (i.e.,
where the life of the mother would be endangered if the fetus were brought to term), the need for skilled
medical management and/or medical services is equally important as in those cases carried to full term.
After the infant is delivered and is a separate individual, items and services furnished to the infant are not
covered on the basis of the mother’s eligibility.
Most surgeons and obstetricians bill patients an all-inclusive package charge intended to cover all services
associated with the surgical procedure or delivery of the child. All expenses for surgical and obstetrical
care, including preoperative/prenatal examinations and tests and post-operative/postnatal services, are
considered incurred on the date of surgery or delivery, as appropriate. This policy applies whether the
physician bills on a package charge basis, or itemizes the bill separately for these items.
Occasionally, a physician’s bill may include charges for additional services not directly related to the
surgical procedure or the delivery. Such charges are considered incurred on the date the additional services
are furnished.
The above policy applies only where the charges are imposed by one physician or by a clinic on behalf of a
group of physicians. Where more than one physician imposes charges for surgical or obstetrical services, all
preoperative/prenatal and post-operative/postnatal services performed by the physician who performed the
surgery or delivery are considered incurred on the date of the surgery or delivery. Expenses for services
rendered by other physicians are considered incurred on the date they were performed.
B. Treatment for Infertility
Reasonable and necessary services associated with treatment for infertility are covered under Medicare.
Infertility is a condition sufficiently at variance with the usual state of health to make it appropriate for a
person who normally is expected to be fertile to seek medical consultation and treatment.
20.2 - Physician Expense for Allergy Treatment
(Rev. 1, 10-01-03)
B3-2005.2, B3-4145
Allergists commonly bill separately for the initial diagnostic workup and for the treatment (See §60.2).
Where it is necessary to provide treatment over an extended period, the allergist may submit a single bill for
all of the treatments, or may bill periodically. In either case the Form CMS-1500 claim shows the
Healthcare Common Procedure Coding System (HCPCS) codes and from and through dates of service, or
the Form CMS-1450 outpatient claim shows the HCPCS code and date of service (except for critical access
hospital (CAH) claims).
20.3 - Artificial Limbs, Braces, and Other Custom Made Items Ordered But Not
Furnished
(Rev. 1, 10-01-03)
B3-2005.3
A. Date of Incurred Expense
If a custom-made item was ordered but not furnished to a beneficiary because the individual died or because
the order was canceled by the beneficiary or because the beneficiary’s condition changed and the item was
no longer reasonable and necessary or appropriate, payment can be made based on the supplier’s expenses.
(See subsection B for determination of the allowed amount.) In such cases, the expense is considered
incurred on the date the beneficiary died or the date the supplier learned of the cancellation or that the item
was no longer reasonable and necessary or appropriate for the beneficiary’s condition. If the beneficiary
died or the beneficiary’s condition changed and the item was no longer reasonable and necessary or
appropriate, payment can be made on either an assigned or unassigned claim. If the beneficiary, for any
other reason, canceled the order, payment can be made to the supplier only.
B. Determination of Allowed Amount
The allowed amount is based on the services furnished and materials used, up to the date the supplier
learned of the beneficiary’s death or of the cancellation of the order or that the item was no longer
reasonable and necessary or appropriate. The A/B MAC (B) or (HHH), or DME MAC as appropriate,
determines the services performed and the allowable amount appropriate in the particular situation. It takes
into account any salvage value of the device to the supplier.
Where a supplier breaches an agreement to make a prosthesis, brace, or other custom-made device for a
Medicare beneficiary, e.g., an unexcused failure to provide the article within the time specified in the
contract, payment may not be made for any work or material expended on the item. Whether a particular
supplier has lived up to its agreement, of course, depends on the facts in the individual case.
30 - Physician Services
(Rev. 10639; Issued: 03-12-2021; Effective: 01-01-2021; Implementation: 04-12-2021)
A. General
Physician services are the professional services performed by a physician or physicians for a patient
including diagnosis, therapy, surgery, consultation, and care plan oversight.
The physician must render the service for the service to be covered. (See Pub. 100-01, Medicare General
Information, Eligibility, and Entitlement Manual, Chapter 5, §70, for definition of physician.) A service
may be considered to be a physician’s service where the physician either examines the patient in person or is
able to visualize some aspect of the patient’s condition without the interposition of a third person’s
judgment. Direct visualization would be possible by means of x-rays, electrocardiogram and
electroencephalogram tapes, tissue samples, etc.
For example, the interpretation by a physician of an actual electrocardiogram or electroencephalogram
reading that has been transmitted via telephone (i.e., electronically rather than by means of a verbal
description) is a covered service.
Professional services of the physician are covered if provided within the United States, and may be
performed in a home, office, institution, or at the scene of an accident. A patient’s home, for this purpose, is
anywhere the patient makes his or her residence, e.g., home for the aged, a nursing home, a relative’s home.
B. Consultations
As of January 1, 2010, CMS no longer recognizes consultation codes for Medicare payment, except for
inpatient telehealth consultation HCPCS G-codes. Instead, physicians and qualified nonphysician
practitioners are instructed to bill a new or established patient office/outpatient visit CPT code or appropriate
hospital or nursing facility care code. For further detail regarding reporting services that would otherwise be
described by the CPT consultation codes (99241-99245 and 99251-99255), see Pub. 100-04, Medicare
Claims Processing Manual, chapter 12, section 30.6. For detailed instructions regarding reporting telehealth
consultation services and other telehealth services, see Pub. 100-04, chapter 12, section 190.3.
C. Patient-Initiated Second Opinions
Patient-initiated second opinions that relate to the medical need for surgery or for major nonsurgical
diagnostic and therapeutic procedures (e.g., invasive diagnostic techniques such as cardiac catheterization
and gastroscopy) are covered under Medicare. In the event that the recommendation of the first and second
physician differs regarding the need for surgery (or other major procedure), a third opinion is also covered.
Second and third opinions are covered even though the surgery or other procedure, if performed, is
determined not covered. Payment may be made for the history and examination of the patient, and for other
covered diagnostic services required to properly evaluate the patient’s need for a procedure and to render a
professional opinion. In some cases, the results of tests done by the first physician may be available to the
second physician.
D. Concurrent Care
Concurrent care exists where more than one physician renders services more extensive than consultative
services during a period of time. The reasonable and necessary services of each physician rendering
concurrent care could be covered where each is required to play an active role in the patient’s treatment, for
example, because of the existence of more than one medical condition requiring diverse specialized medical
services.
In order to determine whether concurrent physicians’ services are reasonable and necessary, the A/B MAC
(B) must decide the following:
1. Whether the patient’s condition warrants the services of more than one physician on an attending
(rather than consultative) basis, and
2. Whether the individual services provided by each physician are reasonable and necessary.
In resolving the first question, the A/B MAC (B) should consider the specialties of the physicians as well as
the patient’s diagnosis, as concurrent care is usually (although not always) initiated because of the existence
of more than one medical condition requiring diverse specialized medical or surgical services. The
specialties of the physicians are an indication of the necessity for concurrent services, but the patient’s
condition and the inherent reasonableness and necessity of the services, as determined by the A/B MAC
(B)’s medical staff in accordance with locality norms, must also be considered. For example, although
cardiology is a sub-specialty of internal medicine, the treatment of both diabetes and of a serious heart
condition might require the concurrent services of two physicians, each practicing in internal medicine but
specializing in different sub-specialties.
While it would not be highly unusual for concurrent care performed by physicians in different specialties
(e.g., a surgeon and an internist) or by physicians in different subspecialties of the same specialty (e.g., an
allergist and a cardiologist) to be found medically necessary, the need for such care by physicians in the
same specialty or subspecialty (e.g., two internists or two cardiologists) would occur infrequently since in
most cases both physicians would possess the skills and knowledge necessary to treat the patient. However,
circumstances could arise which would necessitate such care. For example, a patient may require the
services of two physicians in the same specialty or sub-specialty when one physician has further limited his
or her practice to some unusual aspect of that specialty, e.g., tropical medicine. Similarly, concurrent
services provided by a family physician and an internist may or may not be found to be reasonable and
necessary, depending on the circumstances of the specific case. If it is determined that the services of one of
the physicians are not warranted by the patient’s condition, payment may be made only for the other
physician’s (or physicians’) services.
Once it is determined that the patient requires the active services of more than one physician, the individual
services must be examined for medical necessity, just as where a single physician provides the care. For
example, even if it is determined that the patient requires the concurrent services of both a cardiologist and a
surgeon, payment may not be made for any services rendered by either physician which, for that condition,
exceed normal frequency or duration unless there are special circumstances requiring the additional care.
The A/B MAC (B) must also assure that the services of one physician do not duplicate those provided by
another, e.g., where the family physician visits during the post-operative period primarily as a courtesy to
the patient.
Hospital admission services performed by two physicians for the same beneficiary on the same day could
represent reasonable and necessary services, provided, as stated above, that the patient’s condition
necessitates treatment by both physicians. The level of difficulty of the service provided may vary between
the physicians, depending on the severity of the complaint each one is treating and that physician’s prior
contact with the patient. For example, the admission services performed by a physician who has been
treating a patient over a period of time for a chronic condition would not be as involved as the services
performed by a physician who has had no prior contact with the patient and who has been called in to
diagnose and treat a major acute condition.
A/B MACs (B) should have sufficient means for identifying concurrent care situations. A correct coverage
determination can be made on a concurrent care case only where the claim is sufficiently documented for the
A/B MAC (B) to determine the role each physician played in the patient’s care (i.e., the condition or
conditions for which the physician treated the patient). If, in any case, the role of each physician involved is
not clear, the A/B MAC (B) should request clarification.
E. Completion of Claims Forms
Separate charges for the services of a physician in completing a Form CMS-1500, a statement in lieu of a
Form CMS-1500, or an itemized bill are not covered. Payment for completion of the Form CMS-1500
claim form is considered included in the fee schedule amount.
F. Care Plan Oversight Services
Care plan oversight is supervision of patients under care of home health agencies or hospices that require
complex and multidisciplinary care modalities involving regular physician development and/or revision of
care plans, review of subsequent reports of patient status, review of laboratory and other studies,
communication with other health professionals not employed in the same practice who are involved in the
patient’s care, integration of new information into the care plan, and/or adjustment of medical therapy.
Such services are covered for home health and hospice patients, but are not covered for patients of skilled
nursing facilities (SNFs), nursing home facilities, or hospitals.
These services are covered only if all the following requirements are met:
1. The beneficiary must require complex or multi-disciplinary care modalities requiring ongoing
physician involvement in the patient’s plan of care;
2. The care plan oversight (CPO) services should be furnished during the period in which the
beneficiary was receiving Medicare covered HHA or hospice services;
3. The physician who bills CPO must be the same physician who signed the home health or hospice
plan of care;
4. The physician furnished at least 30 minutes of care plan oversight within the calendar month for
which payment is claimed. Time spent by a physician’s nurse or the time spent consulting with
one’s nurse is not countable toward the 30-minute threshold. Low-intensity services included as part
of other evaluation and management services are not included as part of the 30 minutes required for
coverage;
5. The work included in hospital discharge day management (codes 99238-99239) and discharge from
observation (code 99217) is not countable toward the 30 minutes per month required for work on the
same day as discharge but only for those services separately documented as occurring after the
patient is actually physically discharged from the hospital;
6. The physician provided a covered physician service that required a face-to-face encounter with the
beneficiary within the 6 months immediately preceding the first care plan oversight service. Only
evaluation and management services are acceptable prerequisite face-to-face encounters for CPO.
EKG, lab, and surgical services are not sufficient face-to-face services for CPO;
7. The care plan oversight billed by the physician was not routine post-operative care provided in the
global surgical period of a surgical procedure billed by the physician;
8. If the beneficiary is receiving home health agency services, the physician did not have a significant
financial or contractual interest in the home health agency. A physician who is an employee of a
hospice, including a volunteer medical director, should not bill CPO services. Payment for the
services of a physician employed by the hospice is included in the payment to the hospice;
9. The physician who bills the care plan oversight services is the physician who furnished them;
10. Services provided incident to a physician’s service do not qualify as CPO and do not count toward
the 30-minute requirement;
11. The physician is not billing for the Medicare end stage renal disease (ESRD) capitation payment for
the same beneficiary during the same month; and
12. The physician billing for CPO must document in the patient’s record the services furnished and the
date and length of time associated with those services.
G. Medical Record Documentation for Part B Services
This medical record documentation requirement applies to Part B professional services that are paid under
the Medicare physician fee schedule. Accordingly, for Part B covered services, the certified nurse-midwife,
nurse practitioner, physician assistant, clinical nurse specialist, and any individual who is authorized under
Medicare law to furnish and bill for their professional services, whether or not they are acting in a teaching
role, may review and verify (sign and date), rather than re-document notes in a patient’s medical record
made by physicians, residents, nurses, and students (including students in therapy or other clinical
disciplines), or other members of the medical team, including as applicable, notes documenting the
physician or nonphysician practitioner’s presence and participation in the service.
For documentation requirements specific to E/M services furnished by physicians and certain nonphysician
practitioners, see Chapter 12, section 30.6 of the Medicare Claims Processing Manual, publication 100-04.
30.1 - Provider-Based Physician Services
(Rev. 1, 10-01-03)
A3-3145, B3-2020.6, B3-8000-8099 (only instructions still applicable are included)
Providers may retain physicians on a full-time or part-time basis in, for example, the fields of pathology,
psychiatry, anesthesiology, and radiology, and in many instances (especially in teaching hospitals) in other
fields of medical specialization as well. Any one of these physicians may be engaged in a variety of
activities including teaching, research, administration, supervision of professional or technical personnel,
service on hospital committees, and other hospital-wide activities, as well as direct medical services to
individual patients. The provider’s arrangement may be with a single physician or with a group of
physicians who assume joint responsibility for discharging agreed-upon duties.
It is necessary to distinguish between the medical and surgical services rendered by a physician to an
individual patient, which are paid under Part B, and provider services (including a physician’s services for
the provider) which are paid under Part A. This is necessary because the payments are made from different
trust funds, A/B MACs (A) and (B) are involved in handling the claims, and the method of determining the
payments for Part A benefits differs from the Part B payment calculation.
Provider-based physicians may include those on a salary, or a percentage arrangement, lessors of
departments, etc. (whether or not they bill patients directly). The services to the patient are known as the
professional component. The services to the provider are known as the provider component.
A. The Professional Component
The professional component of a provider-based physician’s services pertains to that part of the physician’s
activities that is directly related to the medical care of the individual patient. It represents remuneration for
the identifiable medical services by the physician that contribute to the diagnosis of the patient’s condition
or to his treatment. These services are covered under Part B. Claims for professional services are processed
by the A/B MAC (B) and are paid, where applicable, under the fee schedule.
B. The Provider Component
The portion of the physician’s activities representing services which are not directly related to an identifiable
part of the medical care of the individual patient is the provider component. Payment for provider
component services can be made only to a provider, and is included in the provider’s prospective payment
system (PPS) rate. Provider services include teaching, research conducted in conjunction with and as part of
patient care (to the extent that such costs are not met by special research funds), administration, general
supervision of professional or technical personnel, laboratory quality control activities, committee work,
performance of autopsies, and attending conferences as part of the physician’s provider service activities.
Such services are covered under Part A where they relate to inpatient services.
30.2 - Teaching Physician Services
(Rev. 1, 10-01-03)
B3-2020.7, B3-8201, and B3-15016
Part B covers services that attending physicians (other than interns and residents) render in the teaching
setting to individual patients. These include such services as reviewing the patient’s history and physical
exams, personally examining the patient within a reasonable time after admission, confirming or revising
diagnoses, determining the course of treatment to be followed, assuring that any supervision needed by
interns or residents is furnished, and making frequent review of the patient’s progress. The medical record
must contain signed or countersigned notes by the physician which show that the physician personally
reviewed the patient’s diagnoses, visited the patient at more critical times of the illness, and discharged the
patient. For other services, such as surgical procedures, notes in the record by interns, residents, or nurses,
which indicate that the physician was physically present when the service was rendered, are sufficient.
Note that, in order to pay a teaching physician under Part B, the teaching physician must at least be present
during the key portion of a service rendered by a resident or intern. When a resident does a visit without
teaching physician presence, the teaching physician must repeat the key portions of the visit and have his
own documentation in order to get paid.
30.3 - Interns and Residents
(Rev. 1, 10-01-03)
B3-2020.8, A3-3115
For Medicare purposes, the terms “interns” and “residents” include physicians participating in approved
postgraduate training programs and physicians who are not in approved programs but who are authorized to
practice only in a hospital setting, e.g., individuals with temporary or restricted licenses, or unlicensed
graduates of foreign medical schools. Where a senior resident has a staff or faculty appointment or is
designated, for example, a “fellow,” it does not change the resident’s status for the purposes of Medicare
coverage and payment. As a general rule, the A/B MAC (A) pays for services of interns and residents as
provider services.
A. Services Furnished by Interns and Residents Within the Scope of an Approved Training Program
Medical and surgical services furnished by interns and residents within the scope of their training program
are covered as provider services. Effective with services furnished on or after July 1, 1987, provider
services includes medical and surgical services furnished in a setting that is not part of the provider, where
the hospital has agreed to incur all or substantially all of the costs of training in the nonprovider facility.
Where the provider does not incur all or substantially all of the training costs and the services are performed
by a licensed physician, the services are payable under Part B by the A/B MAC (B).
B. Services Furnished by Interns and Residents Outside the Scope of an Approved Training Program
- Moonlighting
Medical and surgical services furnished by interns and residents that are not related to their training
program, and are performed outside the facility where they have their training program, are covered as
physician services where the requirements in the first two bullets below are met. Medical and surgical
services furnished by interns and residents that are not related to their training program, and are performed
in an outpatient department or emergency room of the hospital where they have their training program, are
covered as physicians’ services where all three of the following criteria are met:
• The services are identifiable physician services, the nature of which requires performance by a
physician in person and which contribute to the diagnosis or treatment of the patient’s condition;
• The intern or resident is fully licensed to practice medicine, osteopathy, dentistry, or podiatry by the
State in which the services are performed; and
• The services performed can be separately identified from those services that are required as part of
the training program.
When these criteria are met, the services are considered to have been furnished by the individuals in their
capacity as physicians and not in their capacity as interns and residents.
30.4 - Optometrist’s Services
(Rev. 1, 10-01-03)
B3-2020.25
Effective April 1, 1987, a doctor of optometry is considered a physician with respect to all services the
optometrist is authorized to perform under State law or regulation. To be covered under Medicare, the
services must be medically reasonable and necessary for the diagnosis or treatment of illness or injury, and
must meet all applicable coverage requirements. See the Medicare Benefit Policy Manual, Chapter 16,
“General Exclusions from Coverage,” for exclusions from coverage that apply to vision care services, and
the Medicare Claims Processing Manual, Chapter 12, “Physician/Practitioner Billing,” for information
dealing with payment for items and services furnished by optometrists.
A. FDA Monitored Studies of Intraocular Lenses
Special coverage rules apply to situations in which an ophthalmologist is involved in a Food and Drug
Administration (FDA) monitored study of the safety and efficacy of an investigational Intraocular Lens
(IOL). The investigation process for IOLs is unique in that there is a core period and an adjunct period. The
core study is a traditional, well-controlled clinical investigation with full record keeping and reporting
requirements. The adjunct study is essentially an extended distribution phase for lenses in which only
limited safety data are compiled. Depending on the lens being evaluated, the adjunct study may be an
extension of the core study or may be the only type of investigation to which the lens may be subject.
All eye care services related to the investigation of the IOL must be provided by the investigator (i.e., the
implanting ophthalmologist) or another practitioner (including a doctor of optometry) who provides services
at the direction or under the supervision of the investigator and who has an agreement with the investigator
that information on the patient is given to the investigator so that he or she may report on the patient to the
IOL manufacturer.
Eye care services furnished by anyone other than the investigator (or a practitioner who assists the
investigator, as described in the preceding paragraph) are not covered during the period the IOL is being
investigated, unless the services are not related to the investigation.
B. Concurrent Care
Where more than one practitioner furnishes concurrent care, services furnished to a beneficiary by both an
ophthalmologist and another physician (including an optometrist) may be recognized for payment if it is
determined that each practitioner’s services were reasonable and necessary. (See §30.E.)
30.5 - Chiropractor’s Services
(Rev. 23, Issued: 10-08-04, Effective: 10-01-04, Implementation: 10-04-04)
B3-2020.26
A chiropractor must be licensed or legally authorized to furnish chiropractic services by the State or
jurisdiction in which the services are furnished. In addition, a licensed chiropractor must meet the following
uniform minimum standards to be considered a physician for Medicare coverage. Coverage extends only to
treatment by means of manual manipulation of the spine to correct a subluxation provided such treatment is
legal in the State where performed. All other services furnished or ordered by chiropractors are not covered.
If a chiropractor orders, takes, or interprets an x-ray or other diagnostic procedure to demonstrate a
subluxation of the spine, the x-ray can be used for documentation. However, there is no coverage or
payment for these services or for any other diagnostic or therapeutic service ordered or furnished by the
chiropractor. For detailed information on using x-rays to determine subluxation, see §240.1.2.
In addition, in performing manual manipulation of the spine, some chiropractors use manual devices that are
hand-held with the thrust of the force of the device being controlled manually. While such manual
manipulation may be covered, there is no separate payment permitted for use of this device.
A. Uniform Minimum Standards
Prior to July 1, 1974
Chiropractors licensed or authorized to practice prior to July 1, 1974, and those individuals who commenced
their studies in a chiropractic college before that date must meet all of the following three minimum
standards to render payable services under the program:
• Preliminary education equal to the requirements for graduation from an accredited high school or
other secondary school;
• Graduation from a college of chiropractic approved by the State’s chiropractic examiners that
included the completion of a course of study covering a period of not less than 3 school years of 6
months each year in actual continuous attendance covering adequate course of study in the subjects
of anatomy, physiology, symptomatology and diagnosis, hygiene and sanitation, chemistry,
histology, pathology, and principles and practice of chiropractic, including clinical instruction in
vertebral palpation, nerve tracing, and adjusting; and
• Passage of an examination prescribed by the State’s chiropractic examiners covering the subjects
listed above.
After June 30, 1974
Individuals commencing their studies in a chiropractic college after June 30, 1974, must meet all of the
above three standards and all of the following additional requirements:
• Satisfactory completion of 2 years of pre-chiropractic study at the college level;
• Satisfactory completion of a 4-year course of 8 months each year (instead of a 3-year course of 6
months each year) at a college or school of chiropractic that includes not less than 4,000 hours in the
scientific and chiropractic courses specified in the second bullet under “Prior to July 1, 1974”
above, plus courses in the use and effect of x-ray and chiropractic analysis; and
• The practitioner must be over 21 years of age.
B. Maintenance Therapy
Under the Medicare program, Chiropractic maintenance therapy is not considered to be medically
reasonable or necessary, and is therefore not payable. Maintenance therapy is defined as a treatment plan
that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is
performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement
cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes
supportive rather than corrective in nature, the treatment is then considered maintenance therapy. For
information on how to indicate on a claim a treatment is or is not maintenance, see §240.1.3.
30.6 - Indian Health Service (IHS) Physician and Nonphysician Services
(Rev. 86, Issued: 04-18-08, Effective: 09-11-06, Implementation: 05-19-08)
This information can also be found in the Medicare Claims Processing Manual, Publication 100-04, chapter
19.
Section 1880 of Title XVIII of the Social Security Act (the Act) provides an exception for Indian Health
Service to the general prohibition of payment to Federal Agencies.
The following facilities, which were unable to bill for practitioner services prior to BIPA, may now be paid:
• Outpatient departments of IHS operated hospitals that meet the definition of provider-based in 42
CFR 413.65; and
• Outpatient clinics (freestanding) operated by the IHS.
The following facilities, which were limited by §1880 of the Act, may be paid for services under BIPA or
may be paid under another authority under which it qualifies.
• Outpatient departments of tribally operated hospitals that are operated by a tribe or tribal
organization; and
• Other outpatient facilities that are tribally operated regardless of ownership.
See the Medicare Claims Processing Manual chapter 19 for a description of billing procedures, physician
and non-physician services and other Part B services.
30.6.1 - Payment for Medicare Part B Services Furnished by Certain IHS Hospitals and
Clinics
(Rev. 86, Issued: 04-18-08, Effective: 09-11-06, Implementation: 05-19-08)
Section 1880 of the Act, as amended by §630 of the Medicare Modernization Act of 2003 (MMA), expands
the scope of items and services for which payment may be made to IHS facilities, providers and suppliers to
include all Part B covered items and services for which payment may be made under Part B, subject to
certain limitations as specified in §1880(e)(1)(A) of the Act, for a 5-year period beginning January 1, 2005.
Specifically, for the 5-year period beginning January 1, 2005, IHS facilities, providers and suppliers may bill
Medicare for the following Part B services:
• Durable medical equipment
• Prosthetics and orthotics
• Prosthetics devices
• Therapeutic shoes
• Surgical dressings and splint casts
• Drugs (A/B MAC (B) and DME MAC)
• Clinical laboratory services, and
• Ambulance services
• Screening and preventive services not already covered
See Pub. 100.04, chapter 19, Medicare Claims Processing Manual, for more information on these benefits
and the effective date for each of these benefits.
40 - Effect of Beneficiary Agreements Not to Use Medicare Coverage
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
Normally physicians and practitioners are required to submit claims on behalf of beneficiaries for all items
and services they provide for which Medicare payment may be made under Part B. Also, they are not
allowed to charge beneficiaries in excess of the limits on charges that apply to the item or service being
furnished.
However, a physician or practitioner (as defined in §40.4) may opt out of Medicare. A physician or
practitioner who opts out is not required to submit claims on behalf of beneficiaries and also is excluded
from limits on charges for Medicare covered services.
Only physicians and practitioners that are listed in §40.4 may opt out.
• The only situation in which non-opt-out physicians or practitioners, or other suppliers, are not
required to submit claims to Medicare for covered services is where a beneficiary or the
beneficiary’s legal representative refuses, of his/her own free will, to authorize the submission of a
bill to Medicare. However, the limits on what the physician, practitioner, or other supplier may
collect from the beneficiary continue to apply to charges for the covered service, notwithstanding the
absence of a claim to Medicare.
• In some circumstances, a non-opt-out physician/practitioner, or other supplier, is required to provide
an Advance Beneficiary Notice of Noncoverage (ABN) to the beneficiary prior to rendering an item
or service that is usually covered by Medicare but may not be covered in this particular case. (See
the Medicare Claims Processing Manual, chapter 30 for ABN policy and §40.24 of this chapter for a
description of the difference between an ABN and a private contract.) The ABN notifies the
beneficiary that Medicare will likely deny the claim and prompts the beneficiary to choose whether
or not he/she will accept liability for the full cost of the services if Medicare does not pay. The
beneficiary also indicates on the ABN whether or not a claim should be submitted to Medicare.
Providers and suppliers must follow the beneficiary’s directive for claim submission as indicated on
the ABN. Providers and suppliers will not violate the mandatory claim submission rules of
§1848(g)(4) of the Social Security Act when a claim is not submitted per a beneficiary’s written
request on an ABN. Where a valid ABN is given and a claim is submitted, subsequent denial of the
claim relieves the non-opt-out physician/practitioner, or other supplier, of the limitations on charges
that would apply if the services were covered.
Opt-out physicians and practitioners must not use ABNs, because they use private contracts for any item or
service that is, or may be, covered by Medicare (except for emergency or urgent care services (see §40.28)).
Where a physician/practitioner, or other supplier, fails to submit a claim to Medicare on behalf of a
beneficiary for a covered Part B service within 1 year of providing the service, or knowingly and willfully
charges a beneficiary more than the applicable charge limits on a repeated basis, he/she/it may be subject to
civil monetary penalties under §§1848(g)(1) and/or 1848(g)(3) of the Act. Congress enacted these
requirements for the protection of all Part B beneficiaries. Application of these requirements cannot be
negotiated between a physician/practitioner or other supplier and the beneficiary except where a
physician/practitioner is eligible to opt out of Medicare under §40.4 and the remaining requirements of
§§40.1 - 40.38 are met. Agreements with Medicare beneficiaries that are not authorized as described in
these manual sections and that purport to waive the claims filing or charge limitations requirements, or other
Medicare requirements, have no legal force and effect. For example, an agreement between a
physician/practitioner, or other supplier and a beneficiary to exclude services from Medicare coverage, or to
excuse mandatory assignment requirements applicable to certain practitioners, is ineffective.
The A/B MAC (B) will refer such cases to the OIG.
This subsection does not apply to noncovered charges.
40.1 - Private Contracts Between Beneficiaries and Physicians/Practitioners
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
Section 1802 of the Act, as amended by §4507 of the BBA of 1997 and §106 of the Medicare Access and
CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10), permits a physician/practitioner to opt-out
of Medicare and enter into private contracts with Medicare beneficiaries if specific requirements of this
instruction are met.
40.2 - General Rules of Private Contracts
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
The following rules apply to physicians/practitioners who opt-out of Medicare:
• A physician/practitioner may enter into one or more private contracts with Medicare beneficiaries for
the purpose of furnishing items or services that would otherwise be covered by Medicare (provided
the conditions in §40.1 are met).
• A physician/practitioner who enters into at least one private contract with a Medicare beneficiary
(under the conditions of §40.1) and who submits one or more affidavits in accordance with §40.9,
opts-out of Medicare unless the opt-out is terminated early according to §40.35 or unless the
physician/practitioner fails to maintain opt-out. (See §40.11.)
• Valid opt-out affidavits signed on or after June 16, 2015, will automatically renew every 2 years. If
physicians and practitioners who file affidavits effective on or after June 16, 2015, do not want their
opt-out to automatically renew at the end of a 2 year opt-out period, they may cancel the renewal by
notifying all contractors with which they filed an affidavit in writing at least 30 days prior to the start
of the next opt-out period. Valid opt-out affidavits signed before June 16, 2015, will expire 2 years
after the effective date of the opt-out. If physicians and practitioners that filed affidavits effective
before June 16, 2015, want to extend their opt-out, they must submit a renewal affidavit within 30
days after the current opt-out period expires to all contractors with which they would have filed
claims absent the opt-out.
• Both the private contracts described in the first paragraph of this section and the physician’s or
practitioner’s opt-out described in the second paragraph of this section are null and void if the
physician/practitioner fails to properly opt-out in accordance with the conditions of these
instructions.
• Both the private contracts described in the first paragraph of this section and the physician’s or
practitioner’s opt-out described in the second paragraph of this section are null and void for the
remainder of the opt-out period if the physician/practitioner fails to remain in compliance with the
conditions of these instructions during the opt-out period.
• Services furnished under private contracts meeting the requirements of these instructions are not
covered services under Medicare, and no Medicare payment will be made for such services either
directly or indirectly.
40.3 - Effective Date of the Opt-Out Provision
(Rev. 1, 10-01-03)
B3-3044.3
A physician/practitioner may enter into a private contract with a beneficiary for services furnished no earlier
than January 1, 1998.
40.4 - Definition of Physician/Practitioner
(Rev. 62, Issued: 12-22-06, Effective: 11-13-06, Implementation: 04-02-07)
For purposes of this provision, the term “physician” is limited to doctors of medicine; doctors of osteopathy;
doctors of dental surgery or of dental medicine; doctors of podiatric medicine; and doctors of optometry who
are legally authorized to practice dentistry, podiatry, optometry, medicine, or surgery by the State in which
such function or action is performed; no other physicians may opt out. Also, for purposes of this provision,
the term “practitioner” means any of the following to the extent that they are legally authorized to practice
by the State and otherwise meet Medicare requirements:
• Physician assistant;
• Nurse practitioner;
• Clinical nurse specialist;
• Certified registered nurse anesthetist;
• Certified nurse midwife;
• Clinical psychologist;
• Clinical social worker;
• Registered dietitian; or
• Nutrition Professional
The opt out law does not define “physician” to include chiropractors; therefore, they may not opt out of
Medicare and provide services under private contract. Physical therapists in independent practice and
occupational therapists in independent practice cannot opt out because they are not within the opt out law’s
definition of either a “physician” or “practitioner”.
40.5 - When a Physician or Practitioner Opts Out of Medicare
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
When a physician/practitioner opts-out of Medicare, Medicare covers no services provided by that
individual and no Medicare payment can be made to that physician or practitioner directly or on a capitated
basis. Additionally, no Medicare payment may be made to a beneficiary for items or services provided
directly by a physician or practitioner who has opted out of the program.
EXCEPTION: In an emergency or urgent care situation, a physician/practitioner who opts-out may treat a
Medicare beneficiary with whom he/she does not have a private contract and bill for such treatment. In such
a situation, the physician/practitioner may not charge the beneficiary more than what a nonparticipating
physician/practitioner would be permitted to charge and must submit a claim to Medicare on the
beneficiary’s behalf. Payment will be made for Medicare covered items or services furnished in emergency
or urgent situations when the beneficiary has not signed a private contract with that physician/practitioner.
(See §40.28.)
Under the statute, the physician/practitioner cannot choose to opt-out of Medicare for some Medicare
beneficiaries but not others; or for some services but not others. The physician/practitioner who chooses to
opt-out of Medicare may provide covered care to Medicare beneficiaries only through private contracts.
Medicare will make payment for covered, medically necessary services that are ordered or certified by a
physician/practitioner who has opted out of Medicare if the ordering or certifying physician/practitioner has
acquired a National Provider Identifier (NPI), reports his/her Social Security Number, has a valid opt-out
affidavit on file with his or her Medicare Administrative Contractor (MAC), is of a specialty that is eligible
to order and certify, and provided that the services are not furnished by another physician/practitioner who
has also opted out. For example, if an opt-out physician/practitioner admits a beneficiary to a hospital,
Medicare will reimburse the hospital for medically necessary care.
40.6 - When Payment May be Made to a Beneficiary for Service of an Opt-Out
Physician/Practitioner
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
Payment may be made to a beneficiary for services of an opt out physician/practitioner in two cases:
• The services are emergency or urgent care services furnished by an opt-out physician/practitioner to
a beneficiary with whom he/she has not previously entered into a private contract. (See §40.28 for further
discussion of emergency and urgent care services by opt-out physicians and practitioners.); or
• The opt-out physician/practitioner failed to privately contract with the beneficiary for services that
he/she provided that were not emergency or urgent care services. The CMS expects this case to come to the
Medicare A/B MAC (B)’s attention as a result of a complaint from a beneficiary or the beneficiary’s legal
representative, or as a result of the beneficiary or the beneficiary’s legal representative filing a claim for
services furnished by an opt out physician/practitioner. Medicare payment may be made for the claims
submitted by a beneficiary for the services of an opt out physician/practitioner when the
physician/practitioner did not privately contract with the beneficiary for services that were not emergency
care services or urgent care services and that were furnished no later than 15 days after the date of a notice
by the A/B MAC (B) that the physician/practitioner has opted out of Medicare (see 42 CFR 405.435(c)).
Therefore, if the beneficiary submits a claim for a service that was furnished by an opt out
physician/practitioner, then the A/B MAC (B) must contact the opt out physician/practitioner in order to
ascertain whether the beneficiary entered into a private contract with the opt out physician/practitioner.
(Note: The A/B MAC (B) should obtain a copy of the private contract from the opt out
physician/practitioner before denying the beneficiary’s claim if the beneficiary did, in fact, enter into a
private contract with the physician/practitioner.) If the beneficiary did not enter into a private contract with
the physician/practitioner and the beneficiary did not receive notice from the A/B MAC (B) that the
physician/practitioner opted out of Medicare, then Medicare payment may be made to the beneficiary for the
non-emergency and/or non-urgent care services (assuming that the services would otherwise be payable).
On the other hand, if the beneficiary did enter into a private contract with the physician/practitioner for the
services or received services from the physician/practitioner 15 days after the date of a notice by the A/B
MAC (B) that the physician/practitioner has opted out of Medicare, then no Medicare payment may be
made. Moreover, the A/B MAC (B) must follow the procedures outlined in §40.11 for cases in which the
physician/practitioner fails to maintain opt-out. If the physician/practitioner does not respond to the
Medicare A/B MAC (B)’s request for a copy of the private contract within 45 days, the A/B MAC (B) must
make payment to the beneficiary based upon the payment for a nonparticipating physician/practitioner for
that service. It must notify the beneficiary that the physician/practitioner who has opted out must privately
contract with the beneficiary or the beneficiary’s legal representative for services the physician/practitioner
furnished and that no further payment will be made to the beneficiary for services furnished by the opt-out
physician/practitioner after 15 days from the postmark of the notice.
40.7 - Definition of a Private Contract
(Rev. 1, 10-01-03)
B3-3044.7
A “private contract” is a contract between a Medicare beneficiary and a physician or other practitioner who
has opted out of Medicare for two years for all covered items and services the physician/practitioner
furnishes to Medicare beneficiaries. In a private contract, the Medicare beneficiary agrees to give up
Medicare payment for services furnished by the physician/practitioner and to pay the physician/practitioner
without regard to any limits that would otherwise apply to what the physician/practitioner could charge.
Pursuant to the statute, once a physician/practitioner files an affidavit notifying the A/B MAC (B) that the
he/she has opted out of Medicare, the physician/practitioner is out of Medicare for two years from the date
the affidavit is signed (unless the opt-out is terminated early according to §40.35, or unless the he/she fails to
maintain opt-out (See §40.11)). After those two years are over, a physician/practitioner could elect to return
to Medicare or to opt out again. A beneficiary who signs a private contract with a physician/practitioner is
not precluded from receiving services from other physicians and practitioners who have not opted out of
Medicare.
Physicians or practitioners who provide services to Medicare beneficiaries enrolled in the new Medical
Savings Account (MSA) demonstration created by the BBA of 1997 are not required to enter into a private
contract with those beneficiaries and to opt out of Medicare under §1802 of the Act.
40.8 - Requirements of a Private Contract
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
A private contract under this section must:
• Be in writing and in print sufficiently large to ensure that the beneficiary is able to read the contract;
• Clearly state whether the physician/practitioner is excluded from Medicare under §§1128, 1156 or
1892 of the Act;
• State that the beneficiary or the beneficiary’s legal representative accepts full responsibility for
payment of the physician’s or practitioner’s charge for all services furnished by the
physician/practitioner;
• State that the beneficiary or the beneficiary’s legal representative understands that Medicare limits
do not apply to what the physician/practitioner may charge for items or services furnished by the
physician/practitioner;
• State that the beneficiary or the beneficiary’s legal representative agrees not to submit a claim to
Medicare or to ask the physician/practitioner to submit a claim to Medicare;
• State that the beneficiary or the beneficiary’s legal representative understands that Medicare
payment will not be made for any items or services furnished by the physician/practitioner that
would have otherwise been covered by Medicare if there was no private contract and a proper
Medicare claim had been submitted;
• State that the beneficiary or the beneficiary’s legal representative enters into the contract with the
knowledge that the beneficiary has the right to obtain Medicare-covered items and services from
physicians and practitioners who have not opted out of Medicare, and that the beneficiary is not
compelled to enter into private contracts that apply to other Medicare-covered services furnished by
other physicians or practitioners who have not opted out;
• State the expected or known effective date and the expected or known expiration date of the current
2-year opt-out period;
• State that the beneficiary or the beneficiary’s legal representative understands that Medigap plans do
not, and that other supplemental plans may elect not to, make payments for items and services not
paid for by Medicare;
• Be signed by the beneficiary or the beneficiary’s legal representative and by the
physician/practitioner;
• Not be entered into by the beneficiary or by the beneficiary’s legal representative during a time
when the beneficiary requires emergency care services or urgent care services. (However, a
physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in
accordance with §40.28);
• Be provided (a photocopy is permissible) to the beneficiary or to the beneficiary’s legal
representative before items or services are furnished to the beneficiary under the terms of the
contract;
• Be retained (original signatures of both parties required) by the physician/practitioner for the
duration of the current 2-year opt-out period;
• Be made available to CMS upon request; and
• Be entered into for each 2-year opt-out period.
In order for a private contract with a beneficiary to be effective, the physician/practitioner must be opted out
of Medicare. The physician/practitioner’s initial 2-year opt-out period begins the date the affidavit meeting
the requirements of §40.9 is signed, provided the affidavit is filed within 10 days after he or she signs his or
her first private contract with a Medicare beneficiary. Once the physician/practitioner has opted out, such
physician/practitioner must enter into a private contract with each Medicare beneficiary to whom the
physician/practitioner furnishes covered services (even where Medicare payment would be on a capitated
basis or where Medicare would pay an organization for the physician’s or practitioner’s services to the
Medicare beneficiary), with the exception of a Medicare beneficiary needing emergency or urgent care.
When a 2-year opt-out period ends, the physician/practitioner must enter into new private contracts with
each beneficiary for the new 2-year period. The new private contracts must state the expected or known
effective date and the expected or known expiration date of the current 2-year opt-out period.
If a physician/practitioner has opted out of Medicare, the physician/practitioner must use a private contract
for items and services that are, or may be, covered by Medicare (except for emergency or urgent care
services (see §40.28)). An opt-out physician/practitioner is not required to use a private contract for an item
or service that is definitely excluded from coverage by Medicare.
A non-opt-out physician/practitioner, or other supplier, is required to submit a claim for any item or service
that is, or may be, covered by Medicare. Where an item or service may be covered in some circumstances,
but not in others, the physician/practitioner, or other supplier, may provide an Advance Beneficiary Notice
to the beneficiary, which informs the beneficiary that Medicare may not pay for the item or service, and that
if Medicare does not do so, the beneficiary is liable for the full charge. (See §§40, 40.24.)
40.9 - Requirements of the Opt-Out Affidavit
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
The private contracting/opt-out provisions at section 1802(b) of the Act were amended by section 106(a) of
MACRA. Prior to the MACRA amendments, the law specified that physicians and practitioners may opt-
out for a 2-year period. Individuals that wished to renew their opt-out at the end of a 2-year opt-out period
were required to file new affidavits with their MAC. Section 106(a) of the MACRA amends section
1802(b)(3) of the Act to require that opt-out affidavits filed on or after June 16, 2015, automatically renew
every 2 years. Therefore, physicians and practitioners that filed opt-out affidavits on or after June 16, 2015,
are not required to file renewal affidavits to continue their opt-out status. Furthermore, physicians and
practitioners who filed opt-out affidavits on or after June 16, 2015, and who do not want their opt-out status
to automatically renew at the end of a 2-year opt-out period may cancel the automatic extension by notifying
their MACs in writing at least 30 days prior to the start of the next 2-year opt-out period. Valid opt-out
affidavits signed before June 16, 2015, will expire 2 years after the effective date of the opt-out. If
physicians and practitioners that filed affidavits effective before June 16, 2015, want to extend their opt-out,
they must submit a renewal affidavit within 30 days after the current opt-out period expires to all contractors
with which they would have filed claims absent the opt-out.
Under 1802(b)(3)(B) and (D) of the Act and Medicare regulations, a valid affidavit must:
• Be in writing and be signed by the physician/practitioner;
• Contain the physician’s or practitioner’s full name, address, telephone number, NPI or billing
number (if one has been assigned), or, if an NPI has not been assigned, the physician’s or
practitioner’s tax identification number (TIN);
• State that, except for emergency or urgent care services (as specified in §40.28), during the opt-out
period the physician/practitioner will provide services to Medicare beneficiaries only through private
contracts that meet the criteria of §40.8 for services that, but for their provision under a private
contract, would have been Medicare-covered services;
• State that the physician/practitioner will not submit a claim to Medicare for any service furnished to
a Medicare beneficiary during the opt-out period, nor will the physician/practitioner permit any
entity acting on the physician’s/practitioner’s behalf to submit a claim to Medicare for services
furnished to a Medicare beneficiary, except as specified in §40.28;
• State that, during the opt-out period, the physician/practitioner understands that the
physician/practitioner may receive no direct or indirect Medicare payment for services that the
physician/practitioner furnishes to Medicare beneficiaries with whom the physician/practitioner has
privately contracted, whether as an individual, an employee of an organization, a partner in a
partnership, under a reassignment of benefits, or as payment for a service furnished to a Medicare
beneficiary under a Medicare Advantage plan;
• State that a physician/practitioner who opts-out of Medicare acknowledges that, during the opt-out
period, the physician’s/practitioner’s services are not covered under Medicare and that no Medicare
payment may be made to any entity for the physician’s/practitioner’s services, directly or on a
capitated basis;
• State on acknowledgment by the physician/practitioner to the effect that, during the opt-out period,
the physician/practitioner agrees to be bound by the terms of both the affidavit and the private
contracts that the physician/practitioner has entered into;
• Acknowledge that the physician/practitioner recognizes that the terms of the affidavit apply to all
Medicare-covered items and services furnished to Medicare beneficiaries by the
physician/practitioner during the opt-out period (except for emergency or urgent care services
furnished to the beneficiaries with whom the physician/practitioner has not previously privately
contracted) without regard to any payment arrangements the physician/practitioner may make;
• With respect to a physician/practitioner who has signed a Part B participation agreement,
acknowledge that such agreement terminates on the effective date of the affidavit;
• Acknowledge that the physician/practitioner understands that a beneficiary who has not entered into
a private contract and who requires emergency or urgent care services may not be asked to enter into
a private contract with respect to receiving such services and that the rules of §40.28 apply if the
physician/practitioner furnishes such services;
• Identify the physician/practitioner sufficiently so that the Medicare contractor can ensure that no
payment is made to the physician/practitioner during the opt-out period; and
• Be filed with all MACs who have jurisdiction over claims the physician/practitioner would otherwise
file with Medicare, and the initial 2-year opt-out period will begin the date the affidavit meeting the
requirements of 42 C.F.R §405.420 is signed, provided the affidavit is filed within 10 days after the
physician/practitioner signs his or her first private contract with a Medicare beneficiary.
40.10 - Failure to Properly Opt Out
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
A. A physician/practitioner fails to properly opt-out for any of the following reasons:
• Any private contract between the physician/practitioner and a Medicare beneficiary that was entered
into before the affidavit described in §40.9 was filed does not meet the specifications of §40.8; or
• The physician/practitioner fails to submit the affidavit(s) in accordance with §40.9.
B. If a physician/practitioner fails to properly opt-out in accordance with the above paragraphs of
this section, the following will result:
• The physician’s or practitioner’s attempt to opt-out of Medicare is nullified, and all of the private
contracts between the physician/practitioner and Medicare beneficiaries for the 2 year period
covered by the attempted opt-out are deemed null and void;
• The physician/practitioner must submit claims to Medicare for all Medicare-covered items and
services furnished to Medicare beneficiaries, including the items and services furnished under the
nullified contracts. A nonparticipating physician/practitioner is subject to the limiting charge
provision. For items or services paid under the physician fee schedule, the limiting charge is 115
percent of the approved amount for nonparticipating physicians or practitioners. A participating
physician/practitioner is subject to the limitations on charges of the participation agreement the
physician/practitioner signed;
• The physician/practitioner may not reassign any claim except as provided in the Medicare Claims
Processing Manual, Chapter 1, “General Billing Requirements,” §§30.2.12 and 30.2.13;
• The physician/practitioner may neither bill nor collect an amount from the beneficiary except for
applicable deductible and coinsurance amounts; and
• The physician/practitioner may make another attempt to properly opt-out at any time.
40.11 - Failure to Maintain Opt-Out
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
A. Failure to maintain opt-out
A physician/practitioner fails to maintain opt-out under this section if during the opt-out period one of the
following occurs:
• The physician/practitioner has filed an affidavit in accordance with §40.9 and has signed private
contracts in accordance with §40.8, but the physician/practitioner knowingly and willfully submits a
claim for Medicare payment (except as provided in §40.28) or the physician/practitioner receives
Medicare payment directly or indirectly for Medicare-covered services furnished to a Medicare
beneficiary (except as provided in §40.28); or
• The physician/practitioner fails to enter into private contracts with Medicare beneficiaries for the
purpose of furnishing items and services that would otherwise be covered by Medicare, or enters into
private contracts that fail to meet the specifications of §40.8; or
• The physician/practitioner fails to comply with the provisions of §40.28 regarding billing for
emergency care services or urgent care services; or
• The physician/practitioner fails to retain a copy of each private contract that the
physician/practitioner has entered into for the duration of the current 2-year period for which the
contracts are applicable or fails to permit CMS to inspect them upon request.
B. Violation discovered by the Medicare contractor during the current 2-year period.
If a physician/practitioner fails to maintain opt-out in accordance with the provisions outlined in paragraph
(A) of this section, and fails to demonstrate within 45 days of a notice from the Medicare contractor that the
physician/practitioner has taken good faith efforts to maintain opt-out (including by refunding amounts in
excess of the charge limits to the beneficiaries with whom the physician/practitioner did not sign a private
contract), the following will result effective 46 days after the date of the notice for the remainder of the
opt-out period:
1. All of the private contracts between the physician/practitioner and Medicare beneficiaries are deemed
null and void.
2. The physician’s or practitioner’s opt-out of Medicare is nullified.
3. The physician or practitioner must submit claims to Medicare for all Medicare covered items and
services furnished to Medicare beneficiaries.
4. The physician or practitioner or beneficiary will not receive Medicare payment on Medicare claims
for the remainder of the opt-out period, except as stated above.
5. The physician or practitioner is subject to the limiting charge provisions as stated in §40.10.
6. The practitioner may not reassign any claim except as provided in Pub. 100-04, Medicare Claims
Processing Manual, Chapter 1, “General Billing Requirements,” §30.2.13.
7. The practitioner may neither bill nor collect any amount from the beneficiary except for applicable
deductible and coinsurance amounts.
8. The physician or practitioner may not attempt to once more meet the criteria for properly opting out
until the current 2-year period expires.
C. Violation not discovered by the Medicare contractor during the current 2-year period.
• In situations where a violation of paragraph (A) of this section is not discovered by the Medicare
contractor during the 2-year period when the violation actually occurred, the requirements of
paragraphs (B)(1) through (B)(8) of this section are applicable from the date that the first violation
of paragraph (A) of this section occurred until the end of the 2-year period during which the
violation occurred (unless the physician or practitioner takes good faith efforts, within 45 days of
any notice from the Medicare contractor that the physician or practitioner failed to maintain opt-out,
or within 45 days of the physician’s or practitioner’s discovery of the failure to maintain opt-out,
whichever is earlier, to correct his or her violations of paragraph (A) of this section. Good faith
efforts include, but are not necessarily limited to, refunding any amounts collected in excess of the
charge limits from beneficiaries with whom he or she did not sign a private contract).
40.12 - Actions to Take in Cases of Failure to Maintain Opt-Out
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
If the Medicare contractor becomes aware that the physician/practitioner has failed to maintain opt-out as
indicated in §40.11, it must send the physician/practitioner a letter advising the physician/practitioner that it
has received a claim and believes that the physician/ practitioner may have inadvertently failed to maintain
opt-out. It must describe the situation in §40.11 that it believes exists and its basis for its belief. It must ask
the physician or practitioner to provide it with an explanation of what happened and how, within 45 days,
the physician or practitioner will resolve it. (See Pub. 100-04, Medicare Claims Processing Manual, Chapter
1, “General Billing Requirements,” §70.6).
If the Medicare contractor received a claim from the opt-out physician/practitioner, it must ask the
physician/practitioner if the received claim was: (a) an emergency or urgent situation, with missing
documentation, or (b) filed in error. When the reason for the letter is that the physician/practitioner filed a
claim that the physician/practitioner did not identify as an emergency or urgent care service, the Medicare
contractor must request that the physician/practitioner submit the following information with the
physician’s/practitioner’s response:
• Emergency/urgent care documentation if the claim was for a service furnished in an emergency or
urgent situation but included no documentation to that effect; and/or
• If the claim was filed in error, the Medicare contractor must ask the physician/practitioner to explain
whether the filing was an isolated incident or a systematic problem affecting a number of claims.
In the case of any potential failure to maintain opt-out (including but not limited to improper submission of a
claim), the Medicare contractor must explain in its request to the physician or practitioner that it would like
to resolve this matter as soon as possible. It must instruct the physician/practitioner to provide the
information it requested within 45 days of the date of its development letter. It must provide the physician
or practitioner with the name and telephone number of a contact person in case they have any questions.
If the violation was due to a systems problem, the Medicare contractor must ask the physician or practitioner
to include with his or her response an explanation of the actions being taken to correct the problem and
when the physician or practitioner expects the system error to be fixed. If the violation persists beyond the
time period indicated in the physician’s or practitioner’s response, the Medicare contractor must contact the
physician or practitioner again to ascertain why the problem still exists and when the physician or
practitioner expects to have it corrected. It must repeat this process until the system problem is corrected.
Also, in the Medicare contractor’s development request, it must advise the physician or practitioner that if
no response is received by the due date, the Medicare contractor will assume that there has been no
correction of the failure to maintain opt-out and that this could result in a determination that the
physician/practitioner is once again subject to Medicare rules.
In the case of wrongly filed claims, the Medicare contractor must hold the claim and any others it receives
from the physician or practitioner in suspense until it hears from the physician or practitioner or the response
date lapses. In this case, if the physician or practitioner responds that the claim was filed in error, the
Medicare contractor must continue processing the claim, deny the claim, and send the physician or
practitioner the appropriate Remittance Advice and send the beneficiary a Medicare Summary Notice
(MSN) with the appropriate language explaining that the claim was submitted erroneously and the
beneficiary is responsible for the physician’s or practitioner’s charge. In other words, the limiting charge
provision does not apply and the beneficiary is responsible for all charges. This process will apply to all
claims until the physician or practitioner is able to get the problem fixed.
If the Medicare contractor does not receive a response from the physician or practitioner by the development
letter due date or if it is determined that the opt-out physician or practitioner knowingly and willfully failed
to maintain opt-out, it must notify the physician or practitioner that the effects of failure to maintain opt-out
specified in §40.11 apply. It must formally notify the physician/practitioner of this determination and
of the rules that again apply (e.g., mandatory submission of claims, limiting charge, etc.). It must
specifically include in this letter each of the effects of failing to opt-out that are identified in §40.11.
The act of claims submission by the beneficiary for an item or service provided by a physician or
practitioner who has opted out is not a violation by the physician or practitioner and does not nullify the
contract with the beneficiary. However, if there are what the Medicare contractor considers to be a
substantial number of claims submissions by beneficiaries for items or services by an opt-out physician or
practitioner, it must investigate to ensure that contracts between the physician or practitioner and the
beneficiaries exist and that the terms of the contracts meet the Medicare statutory requirements outlined in
this instruction. If noncompliance with the opt-out affidavit is determined, it must develop claims
submission or limiting charge violation cases, as appropriate, based on its findings.
In cases in which the beneficiary files an appeal of the denial of a beneficiary-filed claim for services from
an opt-out physician or practitioner, and alleges that there was no private contract, the Medicare contractor
must ask the physician/practitioner to provide it with a copy of the private contract. Where the physician or
practitioner does not provide a copy of a private contract that meets the requirements of §40.8 and was
signed by the beneficiary before the service was furnished, the Medicare contractor must make payment to
the beneficiary and proceed as described above.
40.13 - Physician/Practitioner Who Has Never Enrolled in Medicare
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
For a physician/practitioner who has never enrolled in the Medicare program and wishes to opt-out of
Medicare, if the physician/practitioner does not have an NPI, then the physician/practitioner must include his
or her TIN on the opt-out affidavit. The Medicare contractor must annotate its in-house provider file that the
physician/practitioner has opted out of the program. The Medicare contractor can get the full name, address,
license number, and tax identification number from the physician’s/practitioner’s opt-out affidavit. All other
data requirements should be developed from other data sources (e.g., the American Medical Association,
State Licensing Board, etc.). The physician/practitioner must not receive payment during the opt-out period
(except in the case of emergency or urgent care services). If the Medicare contractor needs additional data
elements and cannot obtain that information from another source, it may contact the physician/practitioner
directly. It must notify the physician or practitioner that in order to certify or order services for a Medicare
patient, the physician or practitioner must have a valid NPI.
If an opt-out physician/practitioner provides emergency or urgent care service to a beneficiary who has not
signed a private contract with the physician or practitioner and the physician/practitioner submits an
assigned claim, the physician or practitioner must complete Form CMS-855-I and enroll in the Medicare
program before receiving reimbursement. Under a similar circumstance, if the physician or practitioner
submits an unassigned claim, the Medicare contractor must pay the beneficiary directly without requiring a
completed Form CMS-855-I. It may use the information from the affidavit to begin the enrollment process.
40.14 - Nonparticipating Physicians or Practitioners Who Opt Out of Medicare
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
A nonparticipating physician or practitioner may opt-out of Medicare at any time in accordance with the
following:
• The initial 2-year opt-out period begins the date the affidavit meeting the requirements of §40.9
is signed, provided the affidavit is filed within 10 days after the physician or practitioner signs
his or her first private contract with a Medicare beneficiary.
• If the physician or practitioner does not timely file any required affidavit, the initial 2-year opt-
out period begins when the last such affidavit is filed. Any private contract entered into before
the last required affidavit is filed becomes effective upon the filing of the last required affidavit
and the furnishing of any items or services to a Medicare beneficiary under such contract before
the last required affidavit is filed is subject to standard Medicare rules.
40.15 - Excluded Physicians and Practitioners
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
An excluded physician or practitioner may opt out of Medicare by submitting the required documentation in
accordance with §40.9. When determining effective dates of the exclusion versus the opt-out, the date of
exclusion always takes precedence over the date the physician or practitioner opts out of Medicare. A
physician or practitioner who has been excluded must comply with 42 CFR 1001.1901, “Scope and Effect of
Exclusion.”
If an excluded/opt-out physician or practitioner submits a claim to Medicare, the Medicare contractor must
not make payment for services furnished, ordered, or prescribed on or after the effective date of the
exclusion, except in the limited circumstances stated in 42 CFR 1001.1901.
The Medicare contractor must not make payment to a beneficiary who submits claims for services rendered
by an excluded/opt-out physician or practitioner (except where payment would otherwise be made in
accordance with the Medicare Program Integrity Manual). It must deny the claim and send the physician or
practitioner the appropriate remittance and send the beneficiary a MSN as explained in §40.39.
40.16 - Relationship Between Opt-Out and Medicare Participation Agreements
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
Participation agreements will terminate on the opt out effective date. See 40.17 for effective date provisions.
Physicians and practitioners may not provide services under private contracts with beneficiaries earlier than
the effective date of the affidavit. Nonparticipating physicians and practitioners may opt out at any time.
The Medicare contractor must update the system files so that it may timely pay participating physicians and
practitioners at the correct payment amounts in effect for that part of the fee schedule year before they opt
out and to pay them as nonparticipating for emergency or urgent care as of their opt out effective date.
40.17 - Participating Physicians and Practitioners
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
Participating physicians and practitioners may opt out if they file an affidavit that meets the criteria and
which is received by the Medicare contractor at least 30 days before the first day of the next calendar quarter
showing an effective date of the first day in that quarter (i.e., January 1, April 1, July 1, October 1). They
may not provide services under private contracts with beneficiaries earlier than the effective date of the
affidavit.
The 30-day notice is required to allow sufficient time for the Medicare contractor to accomplish the
appropriate system file updates before the effective date. The Medicare contractor must make participating
physician status changes no less frequently than at the beginning of each calendar quarter. Therefore,
participating physicians or practitioners must provide the Medicare contractor with 30 days notice that they
intend to opt out at the beginning of the next calendar quarter.
Participating physicians or practitioners may sign private contracts only after the effective date of affidavits
filed in accordance with §40.9. They may not provide services under private contracts with beneficiaries
earlier than the effective date of the affidavit. It is necessary to treat nonparticipating physicians or
practitioners differently from participating physicians or practitioners in order to assure that participating
physicians or practitioners are paid properly for the services they furnish before the effective date of the
affidavit.
Participating physicians or practitioners are paid at the full fee schedule for the services they furnish to
Medicare beneficiaries. However, the law sets the payment amount for nonparticipating physicians or
practitioners at 95 percent of the payment amount for participating physicians or practitioners.
Participating physicians or practitioners who opt out are treated as nonparticipating physicians or
practitioners as of the effective date of the opt-out affidavit. When a participating physician/practitioner
opts out of Medicare, the Medicare contractor must pay the physician/practitioner at the higher participating
physician/practitioner rate for services rendered in the period before the effective date of the opt-out; and at
the nonparticipating rate for services rendered on and after the opt-out date.
40.18 - Physicians or Practitioners Who Choose to Opt Out of Medicare
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
If a physician/practitioner chooses to opt-out of Medicare, it means that the physician/ practitioner opts-out
for all covered items and services that he or she furnishes. Physicians and practitioners cannot have private
contracts that apply to some covered services they furnish but not to others. For example, if a physician or
practitioner provides laboratory tests or durable medical equipment incident to his or her professional
services and chooses to opt-out of Medicare, then the physician/practitioner has opted out of Medicare for
payment of lab services and Durable Medical Equipment, Prosthetics, and Orthotics (DMEPOS) as well as
for professional services. If a physician or practitioner has a valid opt-out affidavit on file with the MAC,
has a valid NPI, is a specialty that is eligible to order or certify, and refers a beneficiary to a non-opt-out
physician or practitioner for medically necessary services, such as laboratory, DMEPOS or inpatient
hospitalization, Medicare would cover those services.
In addition, because suppliers of DMEPOS, independent diagnostic testing facilities, clinical laboratories,
etc., cannot opt-out, the physician or practitioner owner of such suppliers cannot opt-out as such a supplier.
Therefore, the participating physician or practitioner becomes a nonparticipating physician or practitioner
for purposes of Medicare payment for emergency and urgent care services on the effective date of the opt-
out. (See §40.28).
40.19 - Opt-Out Relationship to Noncovered Services
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
Because Medicare’s rules do not apply to items or services that are categorically not covered by Medicare, a
private contract is not needed to furnish such items or services to Medicare beneficiaries, and Medicare’s
claims filing rules and limits on charges do not apply to such items or services. For example, because
Medicare does not cover hearing aids, a physician or practitioner, or other supplier may furnish a hearing aid
to a Medicare beneficiary and would not be required to file a claim with Medicare; further, the physician,
practitioner, or other supplier would not be subject to any Medicare limit on the amount they could collect
for the hearing aid.
If the item or service is one that is not categorically excluded from coverage by Medicare, but may be
noncovered in a given case (for example, it is covered only where certain clinical criteria are met and there
is a question as to whether the criteria are met), a non-opt-out physician/practitioner or other supplier is not
relieved of his or her obligation to file a claim with Medicare. If the physician or practitioner or other
supplier has given a proper Advance Beneficiary Notice (ABN), he or she may collect from the beneficiary
the full charge if Medicare does deny the claim.
Where a physician or practitioner has opted out of Medicare, he or she must provide covered services only
through private contracts that meet the criteria specified in §40.8 (including items and services that are not
categorically excluded from coverage but may be excluded in a given case). An opt-out physician or
practitioner is prohibited from submitting claims to Medicare (except for emergency or urgent care services
furnished to a beneficiary with whom the physician or practitioner did not have a private contract). (See
§40.12.)
40.20 - Maintaining Information on Opt-Out Physicians
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
The Medicare contractor must maintain information on the opt-out physicians or practitioners. At a
minimum, it must capture the name and TIN of the physician or practitioner, the effective date of the opt-out
affidavit, and the automatic 2-year renewal date for affidavits filed on or after June 16, 2015. If the
physician/practitioner cancels opt-out (see §40.34), then the Medicare contractor must also maintain the
physician/practitioner’s opt-out end date or cancellation date. The Medicare contractor may also include
other provider-specific information it may need. If cost effective, it may house this information on its
provider file.
40.21 - Informing Medicare Managed Care Plans of the Identity of the Opt-Out
Physicians or Practitioners
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
The Medicare contractor must develop data exchange mechanisms for furnishing Medicare managed care
plans in its service area with timely information on physicians and practitioners who have opted out of
Medicare. For example, it may wish to establish an Internet website “Home Page” which houses all of the
information on physicians or practitioners who have opted out. It will need to negotiate appropriate opt-out
information exchange mechanisms with each managed care plan in its service area.
40.22 - Informing the National Supplier Clearinghouse (NSC) of the Identity of the
Opt-Out Physicians or Practitioners
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
The Medicare contractor must notify the NSC directly with timely information on physicians or practitioners
who have opted out of Medicare. An Internet Web site “Home Page” is not an acceptable means of
notifying the NSC. The NSC’s address is as follows:
National Supplier Clearinghouse
P.O. Box 100142
Columbia, SC 29202-3142
40.23 - Organizations That Furnish Physician or Practitioner Services
(Rev. 1, 10-01-03)
B3-3044.23
The opt-out applies to all items or services the physician or practitioner furnishes to Medicare beneficiaries,
regardless of the location where such items or services are furnished.
Where a physician or practitioner opts out and is a member of a group practice or otherwise reassigns his or
her rights to Medicare payment to an organization, the organization may no longer bill Medicare or be paid
by Medicare for services that the physician or practitioner furnishes to Medicare beneficiaries. However, if
the physician or practitioner continues to grant the organization the right to bill and be paid for the services
the physician or practitioner furnishes to patients, the organization may bill and be paid by the beneficiary
for the services that are provided under the private contract. The decision of a physician or practitioner to
opt out of Medicare does not affect the ability of the group practice or organization to bill Medicare for the
services of physicians and practitioners who have not opted out of Medicare.
Corporations, partnerships, or other organizations that bill and are paid by Medicare for the services of
physicians or practitioners who are employees, partners, or have other arrangements that meet the Medicare
reassignment-of-payment rules cannot opt out because they are neither physicians nor practitioners. Of
course, if every physician and practitioner within a corporation, partnership, or other organization opts out,
then such corporation, partnership, or other organization would have, in effect, opted out.
40.24 - The Difference Between Advance Beneficiary Notices (ABN) and Private
Contracts
(Rev. 1, 10-01-03)
B3-3044.24
An Advance Beneficiary Notice (ABN) allows a beneficiary to make an informed consumer decision by
knowing in advance that the beneficiary may have to pay out-of-pocket. An ABN is not needed where the
item or service is categorically excluded from Medicare coverage or outside the scope of the benefit.
An ABN is used when the physician/practitioner believes that Medicare will not make payment, while
private contracts are used for services that are covered by Medicare and for which payment might be made if
a claim were to be submitted.
See the Medicare Claims Processing Manual, chapter 30, for a description of the ABN.
40.25 - Private Contracting Rules When Medicare is the Secondary Payer
(Rev. 1, 10-01-03)
B3-3044.25
The opt-out physician/practitioner must have a private contract with a Medicare beneficiary for all
Medicare-covered services (see §40.7), notwithstanding that Medicare would be the secondary payer in a
given situation. No Medicare primary or secondary payments will be made for items and services furnished
by a physician/practitioner under the private contract.
40.26 - Registration and Identification of Physicians or Practitioners Who Opt Out
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
If the Medicare contractor has the physician’s/practitioner’s NPI, then the Medicare contractor should use it
in order to identify opt-out physicians or practitioners nationwide. However, if the physician/practitioner
does not have an NPI, then the Medicare contractor must use the physician’s or practitioner’s TIN to identify
opt-out physicians or practitioners nationwide.
40.27 - System Identification
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
The Medicare contractor must ensure that its system can automatically identify claims that include services
furnished by providers or practitioners who have opted out of Medicare. It must not make payment to any
opt-out physician/practitioner for items or services furnished on or after the effective date of the physician’s
or practitioner’s opt out affidavit unless there are emergency or urgent care situations involved. In an
emergency or urgent care situation, payment can be made for services furnished to a Medicare beneficiary if
the beneficiary has no contract with the opt-out physician/practitioner. See the following section for related
instructions.
40.28 - Emergency and Urgent Care Situations
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
Payment may be made for services furnished by an opt-out physician or practitioner who has not signed a
private contract with a Medicare beneficiary for emergency or urgent care items and services furnished to, or
ordered or prescribed for, such beneficiary on or after the date the physician opted out.
Where a physician or practitioner who has opted out of Medicare treats a beneficiary with whom the
physician or practitioner does not have a private contract in an emergency or urgent care situation, the
physician or practitioner may not charge the beneficiary more than the Medicare limiting charge for the
service and must submit the claim to Medicare on behalf of the beneficiary for the emergency or urgent care.
Medicare payment may be made to the beneficiary for the Medicare covered services furnished to the
beneficiary.
In other words, where the physician or practitioner provides emergency or urgent care services to the
beneficiary, the physician or practitioner must submit a claim to Medicare, and may collect no more than the
Medicare limiting charge in the case of a physician, or the deductible and coinsurance in the case of a
practitioner. This implements §1802(b)(2)(A)(iii) of the Act, which specifies that the contract may not be
entered into when the beneficiary is in need of emergency or urgent care. Because the services are excluded
from coverage under §1862(a)(19) of the Act only if they are furnished under private contract, CMS
concludes that they are not excluded in this case where there is no private contract, notwithstanding that they
were furnished by an opt-out physician or practitioner. Hence, they are covered services furnished by a
nonparticipating physician or practitioner, and the rules in effect absent the opt-out would apply in these
cases. Specifically, the physician or practitioner may choose to take assignment (thereby agreeing to collect
no more than the Medicare deductible and coinsurance based on the allowed amount from the beneficiary)
or not to take assignment (and to collect no more than the Medicare limiting charge), but the practitioner
must take assignment under §1842(b)(18) of the Act.
Therefore, in this circumstance the physician or practitioner must submit a completed Medicare claim on
behalf of the beneficiary with the appropriate HCPCS code and HCPCS modifier that indicates the services
furnished to the Medicare beneficiary were emergency or urgent care services and the beneficiary does not
have a private contract with the physician or practitioner. If the physician or practitioner did not submit the
GJ national HCPCS modifier, then the Medicare contractor must deny the claim so that the beneficiary can
appeal.
GJ = Opt-out physician/practitioner EMERGENCY OR URGENT SERVICES
This modifier must be used on claims for services rendered by an opt-out physician/ practitioner for an
emergency/urgent care service. The use of this modifier indicates that the service was furnished by an opt-
out physician/practitioner who has not signed a private contract with a Medicare beneficiary for emergency
or urgent care items and services furnished to, or ordered or prescribed for, such beneficiary on or after the
date the physician/practitioner opted out.
The Medicare contractor must deny payment for emergency or urgent care items and services to both an opt-
out physician or practitioner and the beneficiary if these parties have previously entered into a private
contract, i.e., prior to the furnishing of the emergency or urgent care items or services but within the
physician’s or practitioner’s current 2-year period.
Under the emergency and urgent care situation where an opt-out physician or practitioner renders emergency
or urgent service to a Medicare beneficiary (e.g., a fractured leg) who has not entered into a private
agreement with the physician or practitioner, as stated above the physician or practitioner is required to
submit a claim to Medicare with the appropriate modifier (GJ and 54 as discussed further below) and is
subject to all the rules and regulations of Medicare, including the limiting charge. However, if the opt-out
physician or practitioner asks the beneficiary, with whom the physician or practitioner has no private
contract, to return for a follow up visit (e.g., return within 5 to 6 weeks to remove the cast and examine the
leg) the physician or practitioner must ask the beneficiary to sign a private contract. In other words, once a
beneficiary no longer needs emergency or urgent care (i.e., non-urgent follow up care), Medicare cannot pay
for the follow up care and the physician or practitioner can and must, under the opt-out affidavit agreement,
ask the beneficiary to sign a private contract as a condition of further treatment.
The way this would work in the fractured leg example (see previous paragraph) is that the physician or
practitioner would bill Medicare for the setting of the fractured leg with the emergency opt-out HCPCS
modifier (GJ) and the surgical care only modifier (54) to ensure that Medicare does not pay the Evaluation
and Management (E&M) that is in the global fee for the procedure. The physician or practitioner would
then either have the beneficiary sign the private contract or refer the beneficiary to a Medicare physician or
practitioner who would bill Medicare using the post op only modifier to be paid for the post op care in the
global period.
If the beneficiary continues to be in a condition that requires emergency or urgent care (i.e., unconscious or
unstable after surgery for an aneurysm) follow up care would continue to be paid under emergency or urgent
care until such time as the beneficiary no longer needed such care. In the absence of incontrovertible
evidence, CMS recommends accepting what the physician or practitioner says via the modifiers and doing
post-pay records review of frequent users of the opt-out modifier.
40.29 - Definition of Emergency and Urgent Care Situations
(Rev. 206, Issued: 04-10-15, Effective: 07-13-15, Implementation: 07-13-15)
Emergency care services means inpatient or outpatient hospital services that are necessary to prevent death
or serious impairment of health and, because of the danger to life or health, require use of the most
accessible hospital available and equipped to furnish those services. Congress intended that the term
“emergency or urgent care services” not be limited to emergency services since they also included “urgent
care services.” Urgent Care Services are defined in 42 CFR 405.400 as services furnished within 12 hours
in order to avoid the likely onset of an emergency medical condition. For example, if a beneficiary has an
ear infection with significant pain, CMS would view that as requiring treatment to avoid the adverse
consequences of continued pain and perforation of the eardrum. The patient’s condition would not meet the
definition of emergency medical condition because immediate care is not needed to avoid placing the
health of the individual in serious jeopardy or to avoid serious impairment or dysfunction. However,
although it does not meet the definition of emergency care, the beneficiary needs care within a relatively
short period of time (which CMS defines as 12 hours) to avoid adverse consequences, and the beneficiary
may not be able to find another physician or practitioner to provide treatment within 12 hours.
40.30 - Denial of Payment to Employers of Opt-Out Physicians and Practitioners
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
If an opt-out physician or practitioner is employed in a hospital setting and submits bills for which payment
is prohibited, the Medicare contractor usually detects and investigates the situation. However, in some
instances an opt-out physician or practitioner may have a salary arrangement with a hospital or clinic or
work in a group practice and may not directly submit bills for payment. If the Medicare contractor detects
this situation, it must recover the payment made for the opt-out physician/practitioner from the
hospital/clinic/group practice, after appropriate notification.
40.31 - Denial of Payment to Beneficiaries and Others
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
If a beneficiary submits a claim that includes items or services furnished by an opt-out physician or
practitioner on dates on or after the effective date of opt out by such physician or practitioner, the Medicare
contractor must deny such items or services except as permitted by §40.6.
40.32 - Payment for Medically Necessary Services Ordered or Prescribed by an Opt-out
physician or Practitioner
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
If claims are submitted for any items or services ordered or prescribed by an opt out physician or practitioner
under §1802 of the Act, the Medicare contractor may pay for medically necessary services of the furnishing
entity, provided the furnishing entity is not also a physician or practitioner that has opted out of the
Medicare program.
40.33 - Mandatory Claims Submission
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
Section 1848(g)(4) of the Act, “Physician/Practitioner Submission of Claims,” regarding mandatory claims
submission, does not apply once a physician or practitioner signs and submits an affidavit to the Medicare
contractor opting out of the Medicare program, for the duration of the physician’s or practitioner’s opt-out
period, unless the physician or practitioner knowingly and willfully violates a term of the affidavit.
40.34 - Cancellation of Opt-Out
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
A physician or practitioner may cancel opt-out by submitting a written notice to each MAC to which he or
she would file claims absent the opt-out, not later than 30 days before the end of the current 2-year opt-out
period, indicating that the physician or practitioner does not want to extend the application of the opt-out
affidavit for a subsequent 2-year period.
40.35 - Early Termination of Opt-Out
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
If a physician or practitioner changes his or her mind after the Medicare contractor has approved the
affidavit, the opt-out may be terminated within 90 days of the effective date of the affidavit. To properly
terminate an opt-out, a physician or practitioner must:
• Not have previously opted out of Medicare;
• Notify all Medicare contractors, with which the physician or practitioner filed an affidavit, of the
termination of the opt-out no later than 90 days after the effective date of the initial 2-year period;
• Refund to each beneficiary with whom the physician or practitioner has privately contracted all
payment collected in excess of:
º The Medicare limiting charge (in the case of physicians or practitioners); or
º The deductible and coinsurance (in the case of practitioners).
• Notify all beneficiaries with whom the physician or practitioner entered into private contracts of the
physician’s or practitioner’s decision to terminate opt-out and of the beneficiaries’ rights to have
claims filed on their behalf with Medicare for services furnished during the period between the
effective date of the opt-out and the effective date of the termination of the opt-out period.
When the physician or practitioner properly terminates opt-out in accordance with the second bullet above,
the physician or practitioner (who was previously enrolled in Medicare) will be reinstated in Medicare as if
there had been no opt-out, and the provision of §40.3 must not apply unless the physician or practitioner
subsequently properly opts-out.
40.36 - Appeals
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
A determination by CMS that a physician or practitioner has failed to properly opt-out, failed to maintain
opt-out, failed to timely renew opt-out, failed to privately contract, failed to properly terminate opt-out, or
failed to properly cancel opt-out is an initial determination for purposes of 42 CFR 498.3(b).
A determination by CMS that no payment can be made to a beneficiary for the services of a physician who
has opted out is an initial determination for purposes of 42 CFR 405.924.
See the Medicare Claims Processing Manual, Chapter 29, “Appeals of Claims Decisions,” for additional
information on appeals.
40.37 - Application to the Medicare Advantage Program
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
The Medicare Managed Care Manual contains instructions for Medicare Advantage plans about the impact
on managed care.
The manual provides in general that Medicare Advantage plans:
• Must acquire and maintain information from Medicare contractors on physicians and practitioners
who have opted out of Medicare.
• Must make no payment directly or indirectly for Medicare covered services furnished to a Medicare
beneficiary by a physician or practitioner who has opted out of Medicare, except for emergency or
urgent care services furnished to a beneficiary who has not previously entered into a private contract
with the physician or practitioner, in accordance with §40.28.
The Medicare contractor must maintain mutually agreeable means of advising Medicare Advantage plans of
who has opted out. Disputes with Medicare Advantage plans about the provision of opt out information
should be referred to the regional office staff for resolution.
40.38 - Claims Denial Notices to Opt-Out Physicians and Practitioners
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
To ensure that the notice denying payment to the opt-out physician or practitioner indicates the proper
reason for denial of payment, the Medicare contractor must include language in the notice appropriate to
particular circumstances as follows:
• When the claim is submitted inadvertently by the opt-out physician/practitioner, the Medicare
contractor must use claim adjustment reason code 27 (expenses incurred after coverage terminated)
at the claim level with group code PR (patient responsibility) and the remark code MA47:
Our records show that you have opted out of Medicare, agreeing with the patient not
to bill Medicare for services/tests/supplies furnished. As a result, we cannot pay this
claim. The patient is responsible for payment.”
• The Medicare contractor uses the following message when the claim is submitted knowingly and
willfully by the opt-out physician/practitioner. It must use claim adjustment reason code 27
(expenses incurred after coverage terminated) at the claim level with group code PR (patient
responsibility) and the remittance advice remark code MA47 N771 :
Our records show that you have opted out of Medicare, agreeing with the patient not
to bill Medicare for services/tests/supplies furnished. As a result, we cannot pay this
claim. The patient is responsible for payment. Alert: Under Federal law you cannot
charge more than the limiting charge amount.
40.39 - Claims Denial Notices to Beneficiaries
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
To ensure that the notice to the beneficiary indicates the proper reason for denial of payment, the Medicare
contractor must include language in the notice appropriate to particular circumstances as follows:
• It must use the following MSN message when the claim is submitted inadvertently by the opt-out
physician/practitioner:
MSN # 21.20 - “The provider decided to drop out of Medicare. No payment can be
made for this service. You are responsible for this charge.”
• It must use the following message when the claim is submitted knowingly and willfully by the opt-
out physician/practitioner:
MSN # 21.19 - “The provider decided to drop out of Medicare. No payment can be
made for this service. You are responsible for this charge. Under Federal law your
doctor cannot charge you more than the limiting charge amount.”
• It must use the following message when the claim is submitted by the beneficiary for a service
furnished by an opt-out physician/practitioner:
MSN # 21.20 - “The provider decided to drop out of Medicare. No payment can be
made for this service. You are responsible for this charge.”
50 - Drugs and Biologicals
(Rev. 1, 10-01-03)
B3-2049, A3-3112.4.B, HO-230.4.B
The Medicare program provides limited benefits for outpatient drugs. The program covers drugs that are
furnished “incident to” a physician’s service provided that the drugs are not usually self-administered by the
patients who take them.
Generally, drugs and biologicals are covered only if all of the following requirements are met:
• They meet the definition of drugs or biologicals (see §50.1);
• They are of the type that are not usually self-administered. (see §50.2);
• They meet all the general requirements for coverage of items as incident to a physician’s services
(see §§50.1 and 50.3);
• They are reasonable and necessary for the diagnosis or treatment of the illness or injury for which
they are administered according to accepted standards of medical practice (see §50.4);
• They are not excluded as noncovered immunizations (see §50.4.4.2); and
• They have not been determined by the FDA to be less than effective. (See §§50.4.4).
Medicare Part B does generally not cover drugs that can be self-administered, such as those in pill form, or
are used for self-injection. However, the statute provides for the coverage of some self-administered drugs.
Examples of self-administered drugs that are covered include blood-clotting factors, drugs used in
immunosuppressive therapy, erythropoietin for dialysis patients, osteoporosis drugs for certain homebound
patients, and certain oral cancer drugs. (See §110.3 for coverage of drugs, which are necessary to the
effective use of Durable Medical Equipment (DME) or prosthetic devices.)
50.1 - Definition of Drug or Biological
(Rev. 1, 10-01-03)
B3-2049.1
Drugs and biologicals must be determined to meet the statutory definition. Under the statute §1861(t)(1),
payment may be made for a drug or biological only where it is included, or approved for inclusion, in the
latest official edition of the United States Pharmacopoeia National Formulary (USP-NF), the United States
Pharmacopoeia-Drug Information (USD-DI), or the American Dental Association (AOA) Guide to Dental
Therapeutics, except for those drugs and biologicals unfavorably evaluated in the ADA Guide to Dental
Therapeutics. The inclusion of an item in the USP DI does not necessarily mean that the item is a drug or
biological. The USP DI is a database of drug information developed by the U.S. Pharmacopoeia but
maintained by Micromedex, which contains medically accepted uses for generic and brand name drug
products. Inclusion in such reference (or approval by a hospital committee) is a necessary condition for a
product to be considered a drug or biological under the Medicare program, however, it is not enough.
Rather, the product must also meet all other program requirements to be determined to be a drug or
biological. Combination drugs are also included in the definition of drugs if the combination itself or all of
the therapeutic ingredients of the combination are included, or approved for inclusion, in any of the above
drug compendia.
Drugs and biologicals are considered approved for inclusion in a compendium if approved under the
established procedure by the professional organization responsible for revision of the compendium.
50.2 - Determining Self-Administration of Drug or Biological
(Rev. 157, Issued: 06-08-12, Effective: 07-01-12, Implementation: 07-02-12)
The Medicare program provides limited benefits for outpatient prescription drugs. The program covers
drugs that are furnished “incident to” a physician’s service provided that the drugs are not usually self-
administered by the patients who take them. Section 112 of the Benefits, Improvements & Protection Act of
2000 (BIPA) amended sections 1861(s)(2)(A) and 1861(s)(2)(B) of the Act to redefine this exclusion. The
prior statutory language referred to those drugs “which cannot be self-administered.” Implementation of the
BIPA provision requires interpretation of the phrase “not usually self-administered by the patient”.
A. Policy
A/B MACs (A), (B), and (HHH), are instructed to follow the instructions below when applying the
exclusion for drugs that are usually self-administered by the patient. Each individual A/B MAC (A), (B), or
(HHH) must make its own individual determination on each drug. A/B MACs (A), (B), and (HHH) must
continue to apply the policy that not only the drug is medically reasonable and necessary for any individual
claim, but also that the route of administration is medically reasonable and necessary. That is, if a drug is
available in both oral and injectable forms, the injectable form of the drug must be medically reasonable and
necessary as compared to using the oral form.
For certain injectable drugs, it will be apparent due to the nature of the condition(s) for which they are
administered or the usual course of treatment for those conditions, they are, or are not, usually self-
administered. For example, an injectable drug used to treat migraine headaches is usually self-administered.
On the other hand, an injectable drug, administered at the same time as chemotherapy, used to treat anemia
secondary to chemotherapy is not usually self-administered.
B. Administered
The term “administered” refers only to the physical process by which the drug enters the patient’s body. It
does not refer to whether the process is supervised by a medical professional (for example, to observe proper
technique or side-effects of the drug). Injectable drugs, including intravenously administered drugs, are
typically eligible for inclusion under the “incident to” benefit. With limited exceptions, other routes of
administration including, but not limited to, oral drugs, suppositories, topical medications are considered to
be usually self-administered by the patient.
C. Usually
For the purposes of applying this exclusion, the term “usually” means more than 50 percent of the time for
all Medicare beneficiaries who use the drug. Therefore, if a drug is self-administered by more than 50
percent of Medicare beneficiaries, the drug is excluded from coverage and the A/B MAC (A), (B), or (HHH)
may not make any Medicare payment for it. In arriving at a single determination as to whether a drug is
usually self-administered, A/B MACs (A), (B), and (HHH) should make a separate determination for each
indication for a drug as to whether that drug is usually self-administered.
After determining whether a drug is usually self-administered for each indication, A/B MACs (A), (B), or
(HHH) should determine the relative contribution of each indication to total use of the drug (i.e., weighted
average) in order to make an overall determination as to whether the drug is usually self-administered. For
example, if a drug has three indications, is not self-administered for the first indication, but is self
administered for the second and third indications, and the first indication makes up 40 percent of total usage,
the second indication makes up 30 percent of total usage, and the third indication makes up 30 percent of
total usage, then the drug would be considered usually self-administered.
Reliable statistical information on the extent of self-administration by the patient may not always be
available. Consequently, CMS offers the following guidance for each A/B MAC (A)’s, (B)’s, or (HHH)’s
consideration in making this determination in the absence of such data:
1. Absent evidence to the contrary, presume that drugs delivered intravenously are not usually self-
administered by the patient.
2. Absent evidence to the contrary, presume that drugs delivered by intramuscular injection are not usually
self-administered by the patient. (Avonex, for example, is delivered by intramuscular injection, not usually
self-administered by the patient.) The A/B MAC (A), (B), or (HHH) may consider the depth and nature of
the particular intramuscular injection in applying this presumption. In applying this presumption, A/B
MACs (A), (B), and (HHH) should examine the use of the particular drug and consider the following
factors:
3. Absent evidence to the contrary, presume that drugs delivered by subcutaneous injection are self-
administered by the patient. However, A/B MACs (A), (B), and (HHH) should examine the use of the
particular drug and consider the following factors:
A. Acute Condition - Is the condition for which the drug is used an acute condition? If so, it is less
likely that a patient would self-administer the drug. If the condition were longer term, it would be
more likely that the patient would self-administer the drug.
B. Frequency of Administration - How often is the injection given? For example, if the drug is
administered once per month, it is less likely to be self-administered by the patient. However, if it is
administered once or more per week, it is likely that the drug is self-administered by the patient.
In some instances, A/B MACs (B) may have provided payment for one or perhaps several doses of a drug
that would otherwise not be paid for because the drug is usually self-administered. A/B MACs (B) may
have exercised this discretion for limited coverage, for example, during a brief time when the patient is
being trained under the supervision of a physician in the proper technique for self-administration. Medicare
will no longer pay for such doses. In addition, A/B MACs (A) may no longer pay for any drug when it is
administered on an outpatient emergency basis, if the drug is excluded because it is usually self-
administered by the patient.
D. Definition of Acute Condition
For the purposes of determining whether a drug is usually self-administered, an acute condition means a
condition that begins over a short time period, is likely to be of short duration and/or the expected course of
treatment is for a short, finite interval. A course of treatment consisting of scheduled injections lasting less
than 2 weeks, regardless of frequency or route of administration, is considered acute. Evidence to support
this may include Food and Drug Administration (FDA) approval language, package inserts, drug compendia,
and other information.
E. By the Patient
The term “by the patient” means Medicare beneficiaries as a collective whole. The A/B MAC (B) includes
only the patients themselves and not other individuals (that is, spouses, friends, or other care-givers are not
considered the patient). The determination is based on whether the drug is self-administered by the patient a
majority of the time that the drug is used on an outpatient basis by Medicare beneficiaries for medically
necessary indications. The A/B MAC (B) ignores all instances when the drug is administered on an
inpatient basis.
The A/B MAC (B) makes this determination on a drug-by-drug basis, not on a beneficiary-by-beneficiary
basis. In evaluating whether beneficiaries as a collective whole self-administer, individual beneficiaries who
do not have the capacity to self-administer any drug due to a condition other than the condition for which
they are taking the drug in question are not considered. For example, an individual afflicted with paraplegia
or advanced dementia would not have the capacity to self-administer any injectable drug, so such individuals
would not be included in the population upon which the determination for self-administration by the patient
was based. Note that some individuals afflicted with a less severe stage of an otherwise debilitating
condition would be included in the population upon which the determination for “self-administered by the
patient” was based; for example, an early onset of dementia.
F. Evidentiary Criteria
A/B MACs (A), (B), and (HHH), and DME MACs are only required to consider the following types of
evidence: peer reviewed medical literature, standards of medical practice, evidence-based practice
guidelines, FDA approved label, and package inserts. A/B MACs (A), (B), and (HHH), and DME MACs
may also consider other evidence submitted by interested individuals or groups subject to their judgment.
A/B MACs (A), (B), and (HHH), and DME MACs should also use these evidentiary criteria when reviewing
requests for making a determination as to whether a drug is usually self-administered, and requests for
reconsideration of a pending or published determination.
Note that prior to August 1, 2002, one of the principal factors used to determine whether a drug was subject
to the self-administered exclusion was whether the FDA label contained instructions for self-administration.
However, CMS notes that under the new standard, the fact that the FDA label includes instructions for self-
administration is not, by itself, a determining factor that a drug is subject to this exclusion.
G. Provider Notice of Noncovered Drugs
A/B MACs (A), (B), and (HHH), and DME MACs must describe on their Web site the process they will use
to determine whether a drug is usually self-administered and thus does not meet the “incident to” benefit
category. A/B MACs (A), (B), and (HHH), and DME MACs must publish a list of the injectable drugs that
are subject to the self-administered exclusion on their Web site, including the data and rationale that led to
the determination. A/B MACs (A), (B), and (HHH), and DME MACs will report the workload associated
with developing new coverage statements in CAFM 21208.
A/B MACs (A), (B), and (HHH), and DME MACs must provide notice 45 days prior to the date that these
drugs will not be covered. During the 45-day time period, A/B MACs (A), (B), and (HHH), and DME
MACs will maintain existing medical review and payment procedures. After the 45-day notice, A/B MACs
(A), (B), and (HHH), and DME MACs may deny payment for the drugs subject to the notice.
A/B MACs (A), (B), and (HHH), and DME MACs must not develop local coverage determinations (LCDs)
for this purpose because further elaboration to describe drugs that do not meet the ‘incident to’ and the ‘not
usually self-administered’ provisions of the statute are unnecessary. Current LCDs based solely on these
provisions must be withdrawn. LCDs that address the self-administered exclusion and other information
may be reissued absent the self-administered drug exclusion material. A/B MACs (A), (B), and (HHH), and
DME MACs will report this workload in CAFM 21206. However, A/B MACs (A), (B), and (HHH), and
DME MACs may continue to use and write LCDs to describe reasonable and necessary uses of drugs that
are not usually self-administered.
H. Conferences Between A/B MACs (A), (B), and (HHH), and DME MACs
Contractors’ Medical Directors (CMDs) may meet and discuss whether a drug is usually self-administered
without reaching a formal consensus. Each A/B MAC (A), (B), or (HHH), or DME MAC uses its discretion
as to whether or not it will participate in such discussions. Each A/B MAC (A), (B, or (HHH) or DME
MAC) must make its own individual determinations, except that A/B MACs (A) or (HHH) may, at their
discretion, follow the determinations of the A/B MAC (B) with respect to the self-administered exclusion.
I. Beneficiary Appeals
If a beneficiary’s claim for a particular drug is denied because the drug is subject to the “self-administered
drug” exclusion, the beneficiary may appeal the denial. Because it is a “benefit category” denial and not a
denial based on medical necessity, an Advance Beneficiary Notice (ABN) is not required. A “benefit
category” denial (i.e., a denial based on the fact that there is no benefit category under which the drug may
be covered) does not trigger the financial liability protection provisions of Limitation On Liability (under
§1879 of the Act). Therefore, physicians or providers may charge the beneficiary for an excluded drug.
J. Provider and Physician Appeals
A physician accepting assignment may appeal a denial under the provisions found in Pub. 100-04, Medicare
Claims Processing Manual, chapter 29.
K. Reasonable and Necessary
A/B MACs (A) and (B) will make the determination of reasonable and necessary with respect to the medical
appropriateness of a drug to treat the patient’s condition. MACs will continue to make the determination of
whether the intravenous or injection form of a drug is appropriate as opposed to the oral form. MACs will
also continue to make the determination as to whether a physician’s office visit was reasonable and
necessary. However, MACs should not make a determination of whether it was reasonable and necessary
for the patient to choose to have his or her drug administered in the physician’s office or outpatient hospital
setting. That is, while a physician’s office visit may not be reasonable and necessary in a specific situation,
in such a case an injection service would be payable.
L. Reporting Requirements
Each A/B MAC (A), (B), or (HHH), or DME MACs must report to CMS its complete list of injectable drugs
that the A/B MACs (A), (B), or (HHH), or DME MACs has determined are excluded when furnished
incident to a physician’s service on the basis that the drug is usually self-administered. The CMS expects
that A/B MACs (A), (B), and (HHH), and DME MACs will review injectable drugs on a rolling basis and
update their list of excluded drugs as it is developed and no less frequently than annually. For example,
A/B
MACs (A), (B), and (HHH), and DME MACs should not wait to publish this list until every drug has been
reviewed.
A/B MACs (A), (B), and (HHH), and DME MACs must enter their self-administered drug
exclusion list to the Medicare Coverage Database (MCD). This database can be accessed at
www.cms.hhs.gov/mcd. See Pub.100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3,
“Policies
and Guidelines Applied During Review”, for instructions on submitting these lists to the MCD.
M. Drugs Treated as Hospital Outpatient Supplies
In certain circumstances, Medicare pays for drugs that may be considered usually self-administered by the
patient when such drugs function as supplies. This is the case when the drugs provided are an integral
component of a procedure or are directly related to it, i.e., when they facilitate the performance of or
recovery from a particular procedure. Except for the applicable copayment, hospitals may not bill
beneficiaries for these types of drugs because their costs, as supplies, are packaged into the payment for the
procedure with which they are used. Listed below are examples of when drugs are treated as supplies and
hospitals should bill Medicare for the drug as a supply and should not separately bill the beneficiary.
• Sedatives administered to a patient while he or she is in the preoperative area being prepared for a
procedure.
• Mydriatic drops instilled into the eye to dilate the pupils, anti-inflammatory drops, antibiotic
drops/ointments, and ocular hypotensives that are administered to a patient immediately before,
during, or immediately following an ophthalmic procedure. This does not refer to the patient’s eye
drops that the patient uses pre-and postoperatively.
• Barium or low osmolar contrast media provided integral to a diagnostic imaging procedure.
• Topical solution used with photodynamic therapy furnished at the hospital to treat nonhyperkeratotic
actinic keratosis lesions of the face or scalp.
• Antibiotic ointments such as bacitracin, placed on a wound or surgical incision at the completion of a
procedure.
The following are examples of when a drug is not directly related or integral to a procedure, and does not
facilitate the performance of or recovery from a procedure. Therefore the drug is not considered a packaged
supply. In many of these cases the drug itself is the treatment instead of being integral or directly related to
the procedure, or facilitating the performance of or recovery from a particular procedure.
• Drugs given to a patient for his or her continued use at home after leaving the hospital.
• Oral pain medication given to an outpatient who develops a headache while receiving chemotherapy
administration treatment.
• Daily routine insulin or hypertension medication given preoperatively to a patient.
• A fentanyl patch or oral pain medication such as hydrocodone, given to an outpatient presenting with
pain.
• A laxative suppository for constipation while the patient waits to receive an unrelated X-ray.
These two lists of examples may serve to guide hospitals in deciding which drugs are supplies packaged as a
part of a procedure, and thus may be billed under Part B. Hospitals should follow CMS’ guidance for billing
drugs that are packaged and paid as supplies, reporting coded and uncoded drugs with their charges under
the revenue code associated with the cost center under which the hospital accumulates the costs for the
drugs.
50.3 - Incident To Requirements
(Rev. 1, 10-01-03)
B3-2049.3
In order to meet all the general requirements for coverage under the incident-to provision, an FDA approved
drug or biological must:
• Be of a form that is not usually self-administered;
• Must be furnished by a physician; and
• Must be administered by the physician, or by auxiliary personnel employed by the physician and
under the physician’s personal supervision.
The charge, if any, for the drug or biological must be included in the physician’s bill, and the cost of the
drug or biological must represent an expense to the physician. Drugs and biologicals furnished by other
health professionals may also meet these requirements. (See §§170, 180, 190 and 200 for specific
instructions.)
Whole blood is a biological, which cannot be self-administered and is covered when furnished incident to a
physician’s services. Payment may also be made for blood fractions if all coverage requirements are
satisfied and the blood deductible has been met.
50.4 - Reasonableness and Necessity
(Rev. 1, 10-01-03)
B3-2049.4
50.4.1 - Approved Use of Drug
(Rev. 1, 10-01-03)
B3-2049.4
Use of the drug or biological must be safe and effective and otherwise reasonable and necessary. (See the
Medicare Benefit Policy Manual, Chapter 16, “General Exclusions from Coverage,” §20.) Drugs or
biologicals approved for marketing by the Food and Drug Administration (FDA) are considered safe and
effective for purposes of this requirement when used for indications specified on the labeling. Therefore, the
program may pay for the use of an FDA approved drug or biological, if:
• It was injected on or after the date of the FDA’s approval;
• It is reasonable and necessary for the individual patient; and
• All other applicable coverage requirements are met.
The A/B MAC (A), (B), or (HHH), or DME MAC will deny coverage for drugs and biologicals, which have
not received final marketing approval by the FDA unless it receives instructions from CMS to the contrary.
For specific guidelines on coverage of Group C cancer drugs, see the Medicare National Coverage
Determinations Manual.
If there is reason to question whether the FDA has approved a drug or biological for marketing, the MAC
must obtain satisfactory evidence of FDA’s approval. Acceptable evidence includes:
• A copy of the FDA’s letter to the drug’s manufacturer approving the new drug application (NDA);
• A listing of the drug or biological in the FDA’s “Approved Drug Products” or “FDA Drug and
Device Product Approvals”;
• A copy of the manufacturer’s package insert, approved by the FDA as part of the labeling of the
drug, containing its recommended uses and dosage, as well as possible adverse reactions and
recommended precautions in using it; or
• Information from the FDA’s Web site.
When necessary, the regional office (RO) may be able to help in obtaining information.
50.4.2 - Unlabeled Use of Drug
(Rev. 1, 10-01-03)
B3-2049.3
An unlabeled use of a drug is a use that is not included as an indication on the drug’s label as approved by
the FDA. FDA approved drugs used for indications other than what is indicated on the official label may be
covered under Medicare if the A/B MAC (B) determines the use to be medically accepted, taking into
consideration the major drug compendia, authoritative medical literature and/or accepted standards of
medical practice. In the case of drugs used in an anti-cancer chemotherapeutic regimen, unlabeled uses are
covered for a medically accepted indication as defined in §50.5.
These decisions are made by the MAC on a case-by-case basis.
50.4.3 - Examples of Not Reasonable and Necessary
(Rev. 1, 10-01-03)
B3-2049.4
Determinations as to whether medication is reasonable and necessary for an individual patient should be
made on the same basis as all other such determinations (i.e., with the advice of medical consultants and
with reference to accepted standards of medical practice and the medical circumstances of the individual
case). The following guidelines identify three categories with specific examples of situations in which
medications would not be reasonable and necessary according to accepted standards of medical practice:
1. Not for Particular Illness
Medications given for a purpose other than the treatment of a particular condition, illness, or injury are not
covered (except for certain immunizations). Charges for medications, e.g., vitamins, given simply for the
general good and welfare of the patient and not as accepted therapies for a particular illness are excluded
from coverage.
2. Injection Method Not Indicated
Medication given by injection (parenterally) is not covered if standard medical practice indicates that the
administration of the medication by mouth (orally) is effective and is an accepted or preferred method of
administration. For example, the accepted standard of medical practice for the treatment of certain diseases
is to initiate therapy with parenteral penicillin and to complete therapy with oral penicillin. A/B MACs (B)
exclude the entire charge for penicillin injections given after the initiation of therapy if oral penicillin is
indicated unless there are special medical circumstances that justify additional injections.
3. Excessive Medications
Medications administered for treatment of a disease and which exceed the frequency or duration of
injections indicated by accepted standards of medical practice are not covered. For example, the accepted
standard of medical practice in the maintenance treatment of pernicious anemia is one vitamin B-12
injection per month. A/B MACs (B) exclude the entire charge for injections given in excess of this
frequency unless there are special medical circumstances that justify additional injections.
A/B MACs (B) will supplement the guidelines as necessary with guidelines concerning appropriate use of
specific injections in other situations. They will use the guidelines to screen out questionable cases for
special review, further development, or denial when the injection billed for would not be reasonable and
necessary. They will coordinate any type of drug treatment review with the Quality Improvement
Organization (QIO).
If a medication is determined not to be reasonable and necessary for diagnosis or treatment of an illness or
injury according to these guidelines, the A/B MAC (B) or DME MAC excludes the entire charge (i.e., for
both the drug and its administration). Also, A/B MACs (B) exclude from payment any charges for other
services (such as office visits) which were primarily for the purpose of administering a noncovered injection
(i.e., an injection that is not reasonable and necessary for the diagnosis or treatment of an illness or injury).
50.4.4 - Payment for Antigens and Immunizations
(Rev. 1, 10-01-03)
50.4.4.1 - Antigens
(Rev. 186, Issued: 04-16-14, Effective: 01-01 01, Implementation: 05-12-14)
Payment may be made for a reasonable supply of antigens that have been prepared for a particular patient if:
(1) the antigens are prepared by a physician who is a doctor of medicine or osteopathy, and (2) the physician
who prepared the antigens has examined the patient and has determined a plan of treatment and a dosage
regimen.
Antigens must be administered in accordance with the plan of treatment and by a doctor of medicine or
osteopathy or by a properly instructed person (who could be the patient) under the supervision of the doctor.
The associations of allergists that CMS consulted advised that a reasonable supply of antigens is considered
to be not more than a 12-month supply of antigens that has been prepared for a particular patient at any one
time. The purpose of the reasonable supply limitation is to assure that the antigens retain their potency and
effectiveness over the period in which they are to be administered to the patient. (See §§20.2 and 50.2.)
50.4.4.2 - Immunizations
(Rev. 11905; Issued:03- 16-23; Effective:10-19-22; Implementation: 04-17-23)
Vaccinations or inoculations are excluded as immunizations unless they are directly related to the treatment
of an injury or direct exposure to a disease or condition, such as anti-rabies treatment, tetanus antitoxin or
booster vaccine, botulin antitoxin, antivenin sera, or immune globulin. In the absence of injury or direct
exposure, preventive immunization (vaccination or inoculation) against such diseases as smallpox, polio,
diphtheria, etc., is not covered. However, pneumococcal, hepatitis B, influenza virus, and COVID-19
vaccines are exceptions to this rule. (See items A, B, C, and D below.) In cases where a vaccination or
inoculation is excluded from coverage, related charges are also not covered.
A. Pneumococcal Pneumonia Vaccinations
1. Background and History of Coverage:
Section 1861(s)(10)(A) of the Social Security Act and regulations at 42 CFR
410.57 authorize Medicare coverage under Part B for pneumococcal vaccine and
its administration.
For services furnished on or after May 1, 1981 through September 18, 2014, the
Medicare Part B program covered pneumococcal pneumonia vaccine and its
administration when furnished in compliance with any applicable State law by
any provider of services or any entity or individual with a supplier number.
Coverage included an initial vaccine administered only to persons at high risk of
serious pneumococcal disease (including all people 65 and older;
immunocompetent adults at increased risk of pneumococcal disease or its
complications because of chronic illness; and individuals with compromised
immune systems), with revaccination administered only to persons at highest
risk of serious pneumococcal infection and those likely to have a rapid decline in
pneumococcal antibody levels, provided that at least 5 years had passed since the
previous dose of pneumococcal vaccine.
Those administering the vaccine did not require the patient to present an
immunization record prior to administering the pneumococcal vaccine, nor were
they compelled to review the patient’s complete medical record if it was not
available, relying on the patient’s verbal history to determine prior vaccination
status.
Effective for claims with dates of service on and after September 19, 2014, an
initial pneumococcal vaccine may be administered to all Medicare beneficiaries
who have never received a pneumococcal vaccination under Medicare Part B. A
different, second pneumococcal vaccine may be administered 1 year after the
first vaccine was administered (i.e., 11 full months have passed following the
month in which the last pneumococcal vaccine was administered).
Effective July 1, 2000, Medicare no longer required for coverage purposes that a
doctor of medicine or osteopathy order the vaccine. Therefore, a beneficiary
could receive the vaccine upon request without a physician’s order and without
physician supervision.
2. Coverage Requirements:
Effective July 1, 2021, the Centers for Medicare & Medicaid Services (CMS)
updated the Medicare coverage requirements to align with ACIP
recommendations. Adults age ≥65 years who have not previously received
pneumococcal conjugate vaccine (PCV) or whose previous vaccination history
is unknown should receive 1 dose of PCV (either PCV20 or PCV15). When
PCV15 is used, it should be followed by a dose of 23-valent pneumococcal
polysaccharide vaccine (PPSV23).
For those adults age 19–64 years with certain underlying medical conditions or
other risk factors who have not previously received PCV or whose previous
vaccination history is unknown should receive 1 dose of PCV (either PCV20 or
PCV15). When PCV15 is used, it should be followed by a dose of PPSV23.
Underlying medical conditions or other risk factors include alcoholism, chronic
heart disease, chronic liver disease, chronic lung disease, cigarette smoking,
diabetes mellitus, cochlear implant, cerebrospinal fluid leak, congenital or
acquired asplenia, sickle cell disease or other hemoglobinopathies, chronic
renal failure, congenital or acquired immunodeficiencies, generalized
malignancy, HIV infection, Hodgkin disease, iatrogenic immunosuppression,
leukemia, lymphoma, multiple myeloma, nephrotic syndrome and solid organ
transplant.
Clinical guidance shows that when PCV15 is used, the recommended interval
between administration of PCV15 and PPSV23 is ≥1 year. A minimum interval
of 8 weeks can be considered for adults with an immunocompromising
condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk for
invasive pneumococcal disease caused by serotypes unique to PPSV23 in these
vulnerable groups. Immunocompromising conditions include chronic renal
failure, congenital or acquired immunodeficiencies, generalized malignancy,
HIV infection, Hodgkin disease, iatrogenic immunosuppression, leukemia,
lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplant,
congenital or acquired asplenia, sickle cell disease, or other
hemoglobinopathies.
For adults who only received PPSV23, they may receive a PCV (either PCV20
or PCV15) ≥1 year after their last PPSV23 dose. When PCV15 is used in those
with history of PPSV23 receipt, it need not be followed by another dose of
PPSV23.
Effective October 19, 2022, CMS adds the following coverage requirements to align
with additional ACIP recommendations and further clarifies the 2021 update.
For adults aged ≥65 years who completed their vaccine series with both PCV13 and
PPSV23, but no PPSV23 was received at age ≥65, either one dose of PCV20 is
recommended at least 5 years after the last pneumococcal vaccine dose, or complete the
recommended PPSV23 series as previously recommended.
Shared clinical decision-making is recommended regarding administration of PCV20
for adults age ≥65 years who completed their vaccine series with both PCV13 and
PPSV23, and PPSV was received at age ≥65. If a decision to administer PCV20 is
made, a dose of PCV20 is recommended at least 5 years after the last pneumococcal
vaccine dose.
In addition, adults age ≥65 years and adults age 19-64 years with certain underlying
medical conditions or other risk factors who received PCV13 only are recommended to
receive a dose of PCV20 at least 1 year after the PCV13 dose, or PPSV23 as previously
recommended to complete their pneumococcal vaccine series.
ACIP recommends that adults age 19-64 years with certain underlying medical
conditions or other risk factors who have received both PCV13 and PPSV23 with
incomplete vaccination status are recommended to complete their pneumococcal
vaccine series by receiving either a dose of PCV20 at least 5 years after the last
pneumococcal vaccine dose, or PPSV23 as previously recommended.
Those administering the vaccine should not require the patient to present an
immunization record prior to administering the pneumococcal vaccine, nor
should they feel compelled to review the patient’s complete medical record if it
is not available. Instead, provided that the patient is competent, it is acceptable
to rely on the patient’s verbal history to determine prior vaccination status.
Medicare does not require for coverage purposes that a doctor of medicine or
osteopathy order the vaccine. Therefore, the beneficiary may receive the
vaccine upon request without a physician’s order and without physician
supervision.
B. Hepatitis B Vaccine
Effective for services furnished on or after September 1, 1984, P.L. 98-369
provides coverage under Part B for hepatitis B vaccine and its administration,
furnished to a Medicare beneficiary who is at high or intermediate risk of
contracting hepatitis B. High- risk groups currently identified include (see
exception below):
• ESRD patients;
• Hemophiliacs who receive Factor VIII or IX concentrates;
• Clients of institutions for the mentally retarded;
• Persons who live in the same household as a Hepatitis B Virus (HBV) carrier;
• Homosexual men;
• Illicit injectable drug users; and
• Persons diagnosed with diabetes mellitus
Intermediate risk groups currently identified include:
• Staff in institutions for the mentally retarded; and
• Workers in health care professions who have frequent contact
with blood or blood-derived body fluids during routine work.
EXCEPTION: Persons in both of the above-listed groups in paragraph B, would
not be considered at high or intermediate risk of contracting hepatitis B, however,
if there were laboratory evidence positive for antibodies to hepatitis B. (ESRD
patients are routinely tested for hepatitis B antibodies as part of their continuing
monitoring and therapy.)
For Medicare program purposes, the vaccine may be administered upon the order
of a doctor of medicine or osteopathy, by a doctor of medicine or osteopathy, or
by home health agencies, skilled nursing facilities, ESRD facilities, hospital
outpatient departments, and persons recognized under the incident to physicians’
services provision of law.
A charge separate from the ESRD composite rate will be recognized and paid for
administration of the vaccine to ESRD patients.
C. Influenza Virus Vaccine
Effective for services furnished on or after May 1, 1993, the Medicare Part B program covers influenza
virus vaccine and its administration when furnished in compliance with any applicable State law by any
provider of services or any entity or individual with a supplier number. Typically, these vaccines are
administered once a flu season. Medicare does not require, for coverage purposes, that a doctor of medicine
or osteopathy order the vaccine. Therefore, the beneficiary may receive the vaccine upon request without a
physician’s order and without physician supervision.
D. COVID-19 Vaccine
Effective for services furnished on or after November 2, 2020, under the authority of section 1861(s)(10)(A)
of the Act as amended by section 3713 of P.L. 116-136, the Medicare Part B program covers COVID-19
vaccines and their administration when furnished in compliance with any applicable State law by any
provider of services or any entity or individual with a supplier number.
Medicare does not require, for coverage purposes, that a doctor of medicine or osteopathy order the vaccine.
Therefore, the beneficiary may receive the vaccine upon request without a physician’s order and without
physician supervision.
50.4.5 - Off-Label Use of Drugs and Biologicals in an Anti-Cancer Chemotherapeutic
Regimen
(Rev. 212, Issued: 11-06-15, Effective: 08-12-15, Implementation: 02-10-16)
A. Overview
Effective January 1, 1994, off-label, medically accepted indications of Food and Drug Administration-(FDA)
approved drugs and biologicals used in an anti-cancer chemotherapeutic regimen are identified under the
conditions described below. A regimen is a combination of anti-cancer agents clinically recognized for the
treatment of a specific type of cancer. Off-label, medically accepted indications are supported in either one or
more of the compendia or in peer-reviewed medical literature. The contractor may maintain its own
subscriptions to the listed compendia or peer-reviewed publications to determine the medically accepted
indication of drugs or biologicals used off-label in an anti-cancer chemotherapeutic regimen. Compendia
documentation or peer-reviewed literature supporting off-label use by the treating physician may also be
requested of the physician by the contractor.
B. Recent Revisions to the Compendia List
Do not deny coverage based solely on the absence of FDA-approved labeling for the use, if the use is supported
by any of the following compendia and the use is not listed as unsupported, not indicated, not recommended, or
equivalent terms, in any of the following compendia:
Existing - American Hospital Formulary Service-Drug Information (AHFS-DI)
Effective June 5, 2008 - National Comprehensive Cancer Network (NCCN) Drugs and Biologics Compendium
Effective June 10, 2008 - Micromedex DrugDex
Effective July 2, 2008 - Clinical Pharmacology
Effective August 12, 2015 – Lexi-Drugs
The listed compendia employ various rating and recommendation systems that may not be readily cross-walked
from compendium to compendium. In general, a use is identified by a compendium as medically accepted if
the:
1. indication is a Category 1 or 2A in NCCN, or Class I, Class IIa, or Class IIb in DrugDex; or,
2. narrative text in AHFS-DI or Clinical Pharmacology is supportive, or
3. indication is listed in Lexi-Drugs as “Use: Off-Label” and rated as “Evidence Level A”
A use is not medically accepted by a compendium if the:
1. indication is a Category 3 in NCCN or a Class III in DrugDex; or,
2. narrative text in AHFS or Clinical Pharmacology is “not supportive,” or
3. indication is listed in Lexi-Drugs as “Use: Unsupported”
The complete absence of narrative text on a use is considered neither supportive nor non-supportive.
C. Use Supported by Clinical Research That Appears in Peer-Reviewed Medical Literature
Contractors may also identify off-label uses that are supported by clinical research under the conditions identified
in this section. Peer-reviewed medical literature may appear in scientific, medical, and pharmaceutical
publications in which original manuscripts are published, only after having been critically reviewed for scientific
accuracy, validity, and reliability by unbiased, independent experts prior to publication. In-house publications of
entities whose business relates to the manufacture, sale, or distribution of pharmaceutical products are excluded
from consideration. Abstracts (including meeting abstracts) are excluded from consideration.
In determining whether an off-label use is supported, the contractors will evaluate the evidence in published,
peer-reviewed medical literature listed below. When evaluating this literature, they will consider (among other
things) the following:
• Whether the clinical characteristics of the beneficiary and the cancer are adequately represented in the
published evidence.
• Whether the administered chemotherapy regimen is adequately represented in the published evidence.
• Whether the reported study outcomes represent clinically meaningful outcomes experienced by patients.
• Whether the study is appropriate to address the clinical question. The contractor will consider:
1. whether the experimental design, in light of the drugs and conditions under investigation, is
appropriate to address the investigative question. (For example, in some clinical studies, it may be
unnecessary or not feasible to use randomization, double blind trials, placebos, or crossover.);
2. that non-randomized clinical trials with a significant number of subjects may be a basis for supportive
clinical evidence for determining accepted uses of drugs; and,
3. that case reports are generally considered uncontrolled and anecdotal information and do not provide
adequate supportive clinical evidence for determining accepted uses of drugs.
The contractor will use peer-reviewed medical literature appearing in the regular editions of the following
publications, not to include supplement editions privately funded by parties with a vested interest in the
recommendations of the authors:
American Journal of Medicine;
Annals of Internal Medicine;
Annals of Oncology;
Annals of Surgical Oncology;
Biology of Blood and Marrow Transplantation;
Blood;
Bone Marrow Transplantation;
British Journal of Cancer;
British Journal of Hematology;
British Medical Journal;
Cancer;
Clinical Cancer Research;
Drugs;
European Journal of Cancer (formerly the European Journal of Cancer and Clinical Oncology);
Gynecologic Oncology;
International Journal of Radiation, Oncology, Biology, and Physics;
The Journal of the American Medical Association;
Journal of Clinical Oncology;
Journal of the National Cancer Institute;
Journal of the National Comprehensive Cancer Network (NCCN);
Journal of Urology;
Lancet;
Lancet Oncology;
Leukemia;
The New England Journal of Medicine; or
Radiation Oncology
D. Generally
FDA-approved drugs and biologicals may also be considered for use in the determination of medically accepted
indications for off-label use if determined by the contractor to be reasonable and necessary.
If a use is identified as not indicated by the Centers for Medicare and Medicaid Services (CMS) or the FDA, or if
a use is specifically identified as not indicated in one or more of the compendia listed, or if the contractor
determines, based on peer-reviewed medical literature, that a particular use of a drug is not safe and effective, the
off-label usage is not supported and, therefore, the drug is not covered.
50.4.5.1 - Process for Amending the List of Compendia for Determination of Medically-
Accepted Indications for Off-Label Uses of Drugs and Biologicals in an Anti-Cancer
Chemotherapeutic Regimen
(Rev. 120, Issued: 01-29-10, Effective: 01-01-10, Implementation: 03-01-10)
A. Background
In the Physician Fee Schedule final rule for calendar year (CY) 2008, the CMS established a process for
revising the list of compendia, as authorized under section 1861(t)(2) of the Social Security Act, and also
established a definition for “compendium.” At 42 CFR 414.930(a), a compendium is defined “as a
comprehensive listing of FDA-approved drugs and biologicals or a comprehensive listing of a specific
subset of drugs and biologicals in a specialty compendium, for example, a compendium of anti-cancer
treatment.” A compendium: (1) includes a summary of the pharmacologic characteristics of each drug or
biological and may include information on dosage, as well as recommended or endorsed uses in specific
diseases; (2) is indexed by drug or biological, and, (3) effective January 1, 2010, pursuant to section 182(b)
of the Medicare Improvements for Patients and Providers Act (MIPPA), has a publicly transparent process
for evaluating therapies and for identifying potential conflicts of interests. See 42 CFR 414.930(a); 72 FR
66222, 66404, and 74 FR 61901.
B. Desirable Characteristics of Compendia
CMS increased the transparency of the process by incorporating a list of desirable compendium
characteristics outlined by the Medicare Evidence Development and Coverage Advisory Committee
(MedCAC) as criteria for decision-making. The list of desirable compendium characteristics was developed
by the MedCAC during a public session on March 30, 2006. The goal of this session was to review the
evidence and advise CMS on the desirable characteristics of compendia for use in the determination of
medically accepted indications of drugs and biologicals in anti-cancer therapy. As a result of this meeting,
the MedCAC generated the following list of desirable characteristics:
• Extensive breadth of listings,
• Quick processing from application for inclusion to listing,
• Detailed description of the evidence reviewed for every individual listing,
• Use of pre-specified published criteria for weighing evidence,
• Use of prescribed published process for making recommendations,
• Publicly transparent process for evaluating therapies,
• Explicit "Not Recommended" listing when validated evidence is appropriate,
• Explicit listing and recommendations regarding therapies, including sequential use or combination in
relation to other therapies,
• Explicit "Equivocal" listing when validated evidence is equivocal, and,
• Process for public identification and notification of potential conflicts of interest of the compendias’
parent and sibling organizations, reviewers, and committee members, with an established procedure
to manage recognized conflicts.
Furthermore, the provisions discussed in section 182(b) of MIPPA bring more uniformity in compendia
conflict of interest disclosure practices and allow the public the ability to monitor how these policies impact
compendia off-label recommendations.
C. Process for Changing List of Compendia
CMS will provide an annual 30-day open request period starting January 15 for the public to submit requests
for additions or deletions to the compendia list contained on the CMS Web site at
http://www.cms.hhs.gov/CoverageGenInfo/02_compendia.asp.
Complete requests as defined in section 50.4.5.1.D will be posted to the Web site annually by March 15 for
public notice and comment. The request will identify the requestor and the requested action CMS is being
asked to make to the list. Public comments will be accepted for a 30-day period beginning on the day the
request is posted on the Web site. In addition to the annual process, CMS may generate a request for
changes to the list at any time an urgent action is needed to protect the interests of the Medicare program and
its beneficiaries.
D. Content of Requests
For a request to be considered complete, and therefore accepted for review, it must include the following
information:
• The full name and contact information (including the mailing address, e-mail address, and
telephone number) of the requestor. If the requestor is not an individual person, the information shall
identify the officer or other representative who is authorized to act for the requestor on all matters
related to the request.
• Full identification of the compendium that is the subject of the request, including name, publisher,
edition if applicable, date of publication, and any other information needed for the accurate and
precise identification of the specific compendium.
• A complete, written copy of the compendium that is the subject of the request. If the complete
compendium is available electronically, it may be submitted electronically in place of hard copy. If
the compendium is available online, the requestor may provide CMS with electronic access by
furnishing at no cost to the Federal Government sufficient accounts for the purposes and duration of
the review of the application in place of hard copy.
• The specific action that the requestor wishes CMS to take, for example to add or delete a specific
compendium.
• Detailed, specific documentation that the compendium that is the subject of the request does or does
not comply with the conditions of this rule. Broad, nonspecific claims without supporting
documentation cannot be efficiently reviewed; therefore, they will not be accepted.
• A publicly transparent process for evaluating therapies, which includes the following: (1) internal or
external request for listing of a therapy recommendation, including criteria used to evaluate the
request (the complete application), (2) listing of all the evidentiary materials reviewed or considered
for inclusion in the compendium (3) listing of all individuals who substantively participated in the
review and development of the request, and (4) minutes and voting records of meetings for the
review and disposition of the request. The information from an internal or external request for
inclusion of a therapy in a compendium are available to the public for a period of not less than 5
years, which includes availability on the compendium’s Web site for a period of not less than 3
years, coincident with the compendium’s publication.
• A publicly transparent process for identifying potential conflicts of interests that provides: (1) direct
or indirect financial relationships, and (2) ownership or investment interests that exist between
individuals or the spouse or minor child of individuals who have substantively participated in the
development or disposition of compendia recommendations, and the manufacturer or seller of the
drug or biological being reviewed by the compendium. This information shall be identified and
made timely available in response to a public request for a period of not less than 5 years, which
includes availability on the compendium’s Web site for a period of not less than 3 years, coincident
with the compendium’s publication.
A request may have only a single compendium as its subject. This will provide greater clarity to the scope
of the Agency’s review of a given request. A requestor may submit multiple requests, each requesting a
different action.
E. Submission of Requests
Requests must be in writing and submitted in one of the following two ways (no duplicates please):
1. Electronic requests are encouraged to facilitate administrative efficiency. Each solicitation will
include the electronic address for submissions.
2. Hard copy requests can be sent to: Centers for Medicare & Medicaid Services, Coverage and
Analysis Group, Mailstop C1–09–06, 7500 Security Boulevard, Baltimore, MD 21244.
Allow sufficient time for hard copies to be received prior to the close of the open request period.
F. Review of Requests
CMS will consider a compendium’s attainment of the desirable characteristics specified in 50.4.5.1.B when
reviewing requests. CMS may consider additional, reasonable factors in making a determination. For
example, CMS may consider factors that are likely to impact the compendium’s suitability for this use, such
as a change in the compendium’s ownership or affiliation, and the standards applicable to the evidence
considered by the compendium. CMS may consider that broad accessibility by the general public to the
information contained in the compendium may assist beneficiaries, their treating physicians, or both, in
choosing among treatment options. CMS will also consider a compendium’s grading of evidence used in
making recommendations regarding off-label uses, and the process by which the compendium grades the
evidence. CMS may, at its discretion, combine and consider multiple requests that refer to the same
compendium, even if those requests are for different actions. This facilitates administrative efficiency in the
review of requests.
G. Publishing Review Results
CMS will publish decisions on the CMS Web site within 90 days after the close of the public comment
period.
(This instruction was last reviewed by CMS in December 2009.)
50.4.6 - Less Than Effective Drug
(Rev. 1, 10-01-03)
B3-2049.4.C.5
This is a drug that has been determined by the Food and Drug Administration (FDA) to lack substantial
evidence of effectiveness for all labeled indications. Also, a drug that has been the subject of a Notice of an
Opportunity for a Hearing (NOOH) published in the “Federal Register” before being withdrawn from the
market, and for which the Secretary has not determined there is a compelling justification for its medical
need, is considered less than effective. This includes any other drug product that is identical, similar, or
related. Payment may not be made for a less than effective drug.
Because the FDA has not yet completed its identification of drug products that are still on the market,
existing FDA efficacy decisions must be applied to all similar products once they are identified.
50.4.7 - Denial of Medicare Payment for Compounded Drugs Produced in Violation of
Federal Food, Drug, and Cosmetic Act
(Rev. 1, 10-01-03)
B3-2049.4.C.6
The Food and Drug Administration (FDA) has found that, from time to time, firms established as retail
pharmacies engage in mass production of compounded drugs, beyond the normal scope of pharmaceutical
practice, in violation of the Federal Food, Drug, and Cosmetic Act (FFDCA). By compounding drugs on a
large scale, a company may be operating as a drug manufacturer within the meaning of the FFDCA, without
complying with requirements of that law. Such companies may be manufacturing drugs, which are subject
to the new drug application (NDA) requirements of the FFDCA, but for which FDA has not approved an
NDA or which are misbranded or adulterated. If the FDA has not approved the manufacturing and
processing procedures used by these facilities, the FDA has no assurance that the drugs these companies are
producing are safe and effective. The safety and effectiveness issues pertain to such factors as chemical
stability, purity, strength, bioequivalency, and biovailability.
Section 1862(a)(1)(A) of the Act requires that drugs must be reasonable and necessary in order to by
covered under Medicare. This means, in the case of drugs, the FDA must approve them for marketing.
Section 50.4.1 instructs A/B MACs (A) and (B)to deny coverage for drugs that have not received final
marketing approval by the FDA, unless instructed otherwise by CMS. The Medicare Benefit Policy Manual,
Chapter 16, “General Exclusions from Coverage,” §180, instructs A/B MACs (B) to deny coverage of
services related to the use of noncovered drugs as well. Hence, if DME or a prosthetic device is used to
administer a noncovered drug, coverage is denied for both the nonapproved drug and the DME or prosthetic
device.
In those cases in which the FDA has determined that a company is producing compounded drugs in
violation of the FFDCA, Medicare does not pay for the drugs because they do not meet the FDA approval
requirements of the Medicare program. In addition, Medicare does not pay for the DME or prosthetic
device used to administer such a drug if FDA determines that a required NDA has not been approved or that
the drug is misbranded or adulterated.
The CMS will notify the A/B MAC (B) when the FDA has determined that compounded drugs are being
produced in violation of the FFDCA. The A/B MAC (B) does not stop Medicare payment for such a drug
unless it is notified that it is appropriate to do so through a subsequent instruction. In addition, if the A/B
MAC (B) or Regional Offices (ROs) become aware that other companies are possibly operating in violation
of the FFDCA, the A/B MAC (B) or RO notifies:
Centers for Medicare & Medicaid Services
Center for Medicare Management
7500 Security Blvd.
Baltimore, MD 21244-1850
50.4.8 - Process for Amending the List of Compendia for Determination of Medically-
Accepted Indications for Off-Label Uses of Drugs and Biologicals in an Anti-Cancer
Chemotherapeutic Regimen
50.5 - Self-Administered Drugs and Biologicals
(Rev. 1, 10-01-03)
B3-2049.5
Medicare Part B does not cover drugs that are usually self-administered by the patient unless the statute
provides for such coverage. The statute explicitly provides coverage, for blood clotting factors, drugs used
in immunosuppressive therapy, erythropoietin for dialysis patients, certain oral anti-cancer drugs and anti-
emetics used in certain situations.
50.5.1 - Immunosuppressive Drugs
(Rev.11764, Issued: 12-22-2022; Effective: 01-01-2023; Implementation: 01-01-2023)
Until January 1, 1995, immunosuppressive drugs were covered under Part B for a period of one year
following discharge from a hospital for a Medicare covered organ transplant. The CMS interpreted the 1-
year period after the date of the transplant procedure to mean 365 days from the day on which an inpatient is
discharged from the hospital. Beneficiaries are eligible to receive additional Part B coverage within 18
months after the discharge date for drugs furnished in 1995; within 24 months for drugs furnished in 1996;
within 30 months for drugs furnished in 1997; and within 36 months for drugs furnished after 1997.
For immunosuppressive drugs furnished on or after December 21, 2000, this time limit for coverage is
eliminated.
The Consolidated Appropriations Act of 2021 amended section 1836(b) of the Social Security Act to add a
new form of coverage that provides solely for coverage of immunosuppressive drugs beginning January 1,
2023, for eligible individuals whose entitlement to Medicare based on End-Stage Renal Disease (ESRD)
ends the 36
th
month after the month in which the individuals receive a successful kidney transplant. This
new benefit is referred to as the Part B immunosuppressive drug benefit or “Part B-ID.” Refer to Pub. 100-
01, Chapter 2, Section 40.9 for more information on Part B-ID.
Covered drugs include those immunosuppressive drugs that have been specifically labeled as such and
approved for marketing by the FDA. (This is an exception to the standing drug policy which permits
coverage of FDA approved drugs for nonlabeled uses, where such uses are found to be reasonable and
necessary in an individual case.)
Covered drugs also include those prescription drugs, such as prednisone, that are used in conjunction with
immunosuppressive drugs as part of a therapeutic regimen reflected in FDA approved labeling for
immunosuppressive drugs. Therefore, antibiotics, hypertensives, and other drugs that are not directly related
to rejection are not covered.
The FDA has identified and approved for marketing the following specifically labeled immunosuppressive
drugs. They are:
Sandimmune (cyclosporine), Sandoz Pharmaceutical;
Imuran (azathioprine), Burroughs Wellcome;
Atgam (antithymocyte globulin), Upjohn;
Orthoclone OKT3 (Muromonab-CD3), Ortho Pharmaceutical;
Prograf (tacrolimus), Fujisawa USA, Inc;
Celicept (mycophenolate mefetil, Roche Laboratories;
Daclizumab (Zenapax);
Cyclophosphamide (Cytoxan);
Prednisone; and
Prednosolone.
The CMS expects contractors to keep informed of FDA additions to the list of the immunosuppressive
drugs.
50.5.2 - Erythropoietin (EPO)
(Rev. 1, 10-01-03)
A3-3112.4.B.4, HO-230.4.B.4
The statute provides that EPO is covered for the treatment of anemia for patients with chronic renal failure
who are on dialysis. Coverage is available regardless of whether the drug is administered by the patient or
the patient’s caregiver. EPO is a biologically engineered protein which stimulates the bone marrow to make
new red blood cells.
NOTE: Non-ESRD patients who are receiving EPO to treat anemia induced by other conditions such as
chemotherapy or the drug zidovudine (commonly called AZT) must meet the coverage requirements in §50.
EPO is covered for the treatment of anemia for patients with chronic renal failure who are on dialysis when:
• It is administered in the renal dialysis facility; or
• It is self-administered in the home by any dialysis patient (or patient caregiver) who is determined
competent to use the drug and meets the other conditions detailed below.
NOTE: Payment may not be made for EPO under the incident to provision when EPO is administered in
the renal dialysis facility.
Also, in the office setting, reimbursement will be made for the administration charge only for non-ESRD
patients receiving EPO.
50.5.2.1 - Requirements for Medicare Coverage for EPO
(Rev. 1, 10-01-03)
B3-2049.5
Medicare covers EPO and items related to its administration for dialysis patients who use EPO in the home
when the following conditions are met:
A. Patient Care Plan
A dialysis patient who uses EPO in the home must have a current care plan (a copy of which must be
maintained by the designated backup facility for Method II patients) for monitoring home use of EPO that
includes the following:
1. Review of diet and fluid intake for aberrations as indicated by hyperkalemia and elevated blood
pressure secondary to volume overload;
2. Review of medications to ensure adequate provision of supplemental iron;
3. Ongoing evaluations of hematocrit and iron stores;
4. Reevaluation of the dialysis prescription taking into account the patient’s increased appetite and red
blood cell volume;
5. Method for physician and facility (including backup facility for Method II patients) follow-up on
blood tests and a mechanism (such as a patient log) for keeping the physician informed of the results;
6. Training of the patient to identify the signs and symptoms of hypotension and hypertension; and
7. The decrease or discontinuance of EPO if hypertension is uncontrollable.
B. Patient Selection
The dialysis facility, or the physician responsible for all dialysis-related services furnished to the patient,
must make a comprehensive assessment that includes the following:
1. Preselection Monitoring
The patient’s hematocrit (or hemoglobin), serum iron, transferrin saturation, serum ferritin, and blood
pressure must be measured.
2 Conditions the Patient Must Meet
The assessment must find that the patient meets the following conditions:
a. Is a dialysis patient;
b. Has a hematocrit (or comparable hemoglobin level) that is as follows:
• For a patient who is initiating EPO treatment, no higher than 30 percent unless there is
medical documentation showing the need for EPO despite a hematocrit (or
comparable hemoglobin level) higher than 30 percent. Patients with severe angina,
severe pulmonary distress, or severe hypotension may require EPO to prevent adverse
symptoms even if they have higher hematocrit or hemoglobin levels.
• For a patient who has been receiving EPO from the facility or the physician, between
30 and 36 percent.
c. Is under the care of:
• A physician who is responsible for all dialysis-related services and who prescribes the
EPO and follows the drug labeling instructions when monitoring the EPO home
therapy; and
• A renal dialysis facility that establishes the plan of care and monitors the progress of
the home EPO therapy.
3. The assessment must find that the patient or a caregiver meets the following conditions:
• Is trained by the facility to inject EPO and is capable of carrying out the procedure;
• Is capable of reading and understanding the drug labeling; and
• Is trained in, and capable of observing, aseptic techniques.
4. Care and Storage of Drug
The assessment must find that EPO can be stored in the patient’s residence under refrigeration and that the
patient is aware of the potential hazard of a child’s having access to the drug and syringes.
C. Responsibilities of Physician or Dialysis Facility
The patient’s physician or dialysis facility must:
• Develop a protocol that follows the drug label instructions;
• Make the protocol available to the patient to ensure safe and effective home use of EPO;
• Through the amounts prescribed, ensure that the drug on hand at any time does not exceed a 2-month
supply;
• Maintain adequate records to allow quality assurance for review by the Network and State Survey
Agencies. For Method II patients, current records must be provided to and maintained by the
designated backup facility; and
• The dialysis facility must submit claims for EPO, if the facility provides it.
See the Medicare Claims Processing Manual, Chapter 11, “End Stage Renal Disease,” for instructions for
billing and processing claims for EPO under Method 1 and Method 2. Note that hematocrit readings are
required on claims. It is expected that the ESRD facility or hospital outpatient department will maintain the
following information in each patient’s medical record to permit the review of the medical necessity of EPO.
1. Diagnostic coding;
2. Most recent creatinine prior to initiation of EPO therapy;
3. Date of most recent creatinine prior to initiation of EPO therapy;
4. Most recent hematocrit (HCT) prior to initiation of EPO therapy;
5. Date of most recent hematocrit (HCT) prior to initiation of EPO therapy;
6. Dosage in units/kg;
7. Weight in kgs; and
8. Number of units administered.
50.5.2.2 - Medicare Coverage of Epoetin Alfa (Procrit) for Preoperative Use
(Rev. 1, 10-01-03)
PM-AB-99-59, Dated 8/1/99
This instruction pertains exclusively to the preoperative surgical indication of the drug Procrit, in which it is
administered to specific patients prior to surgery to reduce risk of transfusion. It does not affect Medicare
policies related to other Food and Drug Administration (FDA) approved uses of Procrit. It is not a national
coverage decision.
Procrit as Preventive Service
The A/B MAC (B) may determine that Procrit is covered for individuals who:
1. Are undergoing hip or knee surgery
2. Have an anemia with a hemoglobin between 10 and 13 mg/dL;
3. Are not a candidate for autologous blood transfusion;
4. Are expected to lose more than 2 units of blood; and
5. Have had a workup so that their anemia appears to be that of chronic disease.
The preoperative use of Procrit may be afforded to these individuals when A/B MACs (B), exercising their
discretion, determine that this treatment is reasonable and necessary. In other cases, Procrit is considered a
preventive service and therefore not covered.
50.5.3 - Oral Anti-Cancer Drugs
(Rev. 1, 10-01-03)
A3-3112.4.B.5, HO-230.4.B.5
Effective January 1, 1994, Medicare Part B coverage is extended to include oral anti-cancer drugs that are
prescribed as anti-cancer chemotherapeutic agents providing they have the same active ingredients and are
used for the same indications as anti-cancer chemotherapeutic agents which would be covered if they were
not self-administered and they were furnished incident to a physician’s service as drugs and biologicals.
For an oral anti-cancer drug to be covered under Part B, it must:
• Be prescribed by a physician or other practitioner licensed under State law to prescribe such drugs as
anti-cancer chemotherapeutic agents;
• Be a drug or biological that has been approved by the Food and Drug Administration (FDA);
• Have the same active ingredients as a non-self-administrable anti-cancer chemotherapeutic drug or
biological that is covered when furnished incident to a physician’s service. The oral anti-cancer drug
and the non-self-administrable drug must have the same chemical/generic name as indicated by the
FDA’s “Approved Drug Products” (Orange Book), “Physician’s Desk Reference” (PDR), or an
authoritative drug compendium;
• Be used for the same indications, including unlabeled uses, as the non-self-administrable version of
the drug; and
• Be reasonable and necessary for the individual patient.
50.5.4 - Oral Anti-Nausea (Anti-Emetic) Drugs
(Rev. 185, Issued: 04-15-14, Effective: 05-29-13, Implementation: 07-07-14)
Effective January 1, 1998, Medicare also covers self-administered anti-emetics, which are necessary for the
administration and absorption of the anti-neoplastic chemotherapeutic agents when a high likelihood of
vomiting exists. The anti-emetic drug is covered as a necessary means for administration of the anti-
neoplastic chemotherapeutic agents. Oral drugs prescribed for use with the primary drug, which enhance the
anti-neoplastic effect of the primary drug or permit the patient to tolerate the primary anti-neoplastic drug in
higher doses for longer periods, are not covered. Self-administered anti-emetics to reduce the side effects of
nausea and vomiting brought on by the primary drug are not included beyond the administration necessary
to achieve drug absorption.
Section 1861(s)(2) of the Social Security Act extends coverage to oral anti-emetic drugs that are used as full
replacement for intravenous dosage forms of a cancer regimen under the following conditions:
• Coverage is provided only for oral drugs approved by the Food and Drug Administration (FDA) for
use as anti-emetics;
• The oral anti-emetic must either be administered by the treating physician or in accordance with a
written order from the physician as part of a cancer chemotherapy regimen;
• Oral anti-emetic drugs administered with a particular chemotherapy treatment must be initiated
within 2 hours of the administration of the chemotherapeutic agent and may be continued for a
period not to exceed 48 hours from that time;
• The oral anti-emetic drugs provided must be used as a full therapeutic replacement for the
intravenous anti-emetic drugs that would have otherwise been administered at the time of the
chemotherapy treatment.
Only drugs pursuant to a physician’s order at the time of the chemotherapy treatment qualify for this benefit.
The dispensed number of dosage units may not exceed a loading dose administered within two hours of the
treatment, plus a supply of additional dosage units not to exceed 48 hours of therapy.
Oral drugs that are not approved by the FDA for use as anti-emetics and which are used by treating
physicians adjunctively in a manner incidental to cancer chemotherapy are not covered by this benefit and
are not reimbursable within the scope of this benefit.
It is recognized that a limited number of patients will fail on oral anti-emetic drugs. Intravenous anti-emetics
may be covered (subject to the rules of medical necessity) when furnished to patients who fail on oral anti-
emetic therapy.
More than one oral anti emetic drug may be prescribed and may be covered for concurrent use if needed to
fully replace the intravenous drugs that otherwise would be given. See the Medicare National Coverage
Determinations Manual, Publication 100-03, Chapter 1, Section 110.18, for detailed coverage criteria.
50.5.5 - Hemophilia Clotting Factors
(Rev. 1, 10-01-03)
A3-3112.4.B.2, HO-230.4.B.2
Section 1861(s)(2)(I) of the Act provides Medicare coverage of blood clotting factors for hemophilia
patients competent to use such factors to control bleeding without medical supervision, and items related to
the administration of such factors. Hemophilia, a blood disorder characterized by prolonged coagulation
time, is caused by deficiency of a factor in plasma necessary for blood to clot. For purposes of Medicare
Part B coverage, hemophilia encompasses the following conditions:
• Factor VIII deficiency (classic hemophilia);
• Factor IX deficiency (also termed plasma thromboplastin component (PTC) or Christmas factor
deficiency); and
• Von Willebrand’s disease.
Claims for blood clotting factors for hemophilia patients with these diagnoses may be covered if the patient
is competent to use such factors without medical supervision.
The amount of clotting factors determined to be necessary to have on hand and thus covered under this
provision is based on the historical utilization pattern or profile developed by the contractor for each patient.
It is expected that the treating source, e.g., a family physician or comprehensive hemophilia diagnostic and
treatment center, have such information. From this data, the contractor is able to anticipate and make
reasonable projections concerning the quantity of clotting factors the patient will need over a specific period
of time. Unanticipated occurrences involving extraordinary events, such as automobile accidents or
inpatient hospital stays, will change this base line data and should be appropriately considered. In addition,
changes in a patient’s medical needs over a period of time require adjustments in the profile.
50.6 – Coverage of Intravenous Immune Globulin for Treatment of Primary Immune
Deficiency Diseases in the Home
(Rev. 12352, Issued: 11-08-23, Effective: 01-01-24, Implementation: 01-02-24)
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provides coverage
of intravenous immune globulin (IVIG) for the treatment of primary immune deficiency diseases in
the home (ICD-10-CM codes G11.3, D80.0, D80.2, D80.3, D80.4, D80.5, D80.6, D80.7, D81.0,
D81.1, D81.2, D81.5, D81.6, D81.7, D81.82, D81.89, D81.9, D82.0, D82.1, D82.4, D83.0, D83.1,
D83.2, D83.8, or D83.9 if only
an unspecified diagnosis is necessary). The Act defines “intravenous immune globulin” as an
approved pooled plasma derivative for the treatment of primary immune deficiency disease. It is
covered under this benefit when the patient has a diagnosed primary immune deficiency disease, it
is administered in the home of a patient with a diagnosed primary immune deficiency disease, and
the physician determines that administration of the derivative in the patient’s home is medically
appropriate. For coverage of IVIG under this benefit, it is not necessary for the derivative to be
administered through a piece of durable medical equipment. Division FF, section 4134 of the
Consolidated Appropriation Act, 2023 mandated that CMS establish a permanent, bundled payment
for items and services related to administration of IVIG in a patient’s home. The permanent, bundled
home IVIG items and services payment is effective for home IVIG infusions furnished on or after
January 1, 2024. Payment for these items and services is required to be a separate bundled payment
made to a durable medical equipment supplier for all items and services furnished in the home
during a calendar day. It is up to the provider to determine the services and supplies that are
appropriate and necessary to administer the IVIG for each individual. This may or may not include
the use of a pump; however, a pump is not covered under the home IVIG items and services
payment.
60 - Services and Supplies Furnished Incident To a Physician’s/NPP’s Professional
Service
(Rev. 12425; Issued: 12-21-23: Effective: 01-01-24; Implementation: 01-02-24)
B3-2050
A - Noninstitutional Setting
For purposes of this section a noninstitutional setting means all settings other than a hospital or skilled
nursing facility
Medicare pays for services and supplies (including drug and biologicals which are not usually self-
administered) that are furnished incident to a physician’s or other practitioner’s services, are commonly
included in the physician’s or practitioner’s bills, and for which payment is not made under a separate
benefit category listed in §1861(s) of the Act. A/B MACs (A) and (B) must not apply incident to
requirements to services having their own benefit category. Rather, these services should meet the
requirements of their own benefit category. For example, diagnostic tests are covered under §1861(s)(3)
of the Act and are subject to their own coverage requirements. Depending on the particular tests, the
supervision requirement for diagnostic tests or other services may be more or less stringent than
supervision requirements for services and supplies furnished incident to physician’s or other
practitioner’s services. Diagnostic tests need not also meet the incident to requirement in this section.
Likewise, pneumococcal, influenza, and hepatitis B vaccines are covered under §1861(s)(10) of the Act
and need not also meet incident to requirements. (Physician assistants, nurse practitioners, clinical nurse
specialists, certified nurse midwives, clinical psychologists, clinical social workers, physical therapists
and occupational therapists all have their own benefit categories and may provide services without direct
physician supervision and bill directly for these services. When their services are provided as auxiliary
personnel (see under direct physician supervision, they may be covered as incident to services, in which
case the incident to requirements would apply.
For purposes of this section, physician means physician or other practitioner (physician, physician
assistant, nurse practitioner, clinical nurse specialist, nurse midwife, and clinical psychologist)
authorized by the Act to receive payment for services incident to his or her own services.
To be covered incident to the services of a physician or other practitioner, services and supplies must be:
• An integral, although incidental, part of the physician’s professional service (see
§60.1);
• Commonly rendered without charge or included in the physician’s bill (see §60.1A);
• Of a type that are commonly furnished in physician’s offices or clinics (see §60.1A);
• Furnished by the physician or by auxiliary personnel under the physician’s direct
supervision (see §60.1B).
B - Institutional Setting
Hospital services incident to physician’s or other practitioner’s services rendered to outpatients
(including drugs and biologicals which are not usually self-administered by the patient), and partial
hospitalization and intensive outpatient services incident to such services may also be covered.
The hospital’s A/B MAC (A) makes payment for these services under Part B to a hospital.
60.1 - Incident To Physician’s Professional Services
(Rev. 1, 10-01-03)
B3-2050.1
Incident to a physician’s professional services means that the services or supplies are furnished as an
integral, although incidental, part of the physician’s personal professional services in the course of diagnosis
or treatment of an injury or illness.
A - Commonly Furnished in Physicians’ Offices
Services and supplies commonly furnished in physicians’ offices are covered under the incident to
provision. Where supplies are clearly of a type a physician is not expected to have on hand in his/her office
or where services are of a type not considered medically appropriate to provide in the office setting, they
would not be covered under the incident to provision.
Supplies usually furnished by the physician in the course of performing his/her services, e.g., gauze,
ointments, bandages, and oxygen, are also covered. Charges for such services and supplies must be included
in the physicians’ bills. (See §50 regarding coverage of drugs and biologicals under this provision.) To be
covered, supplies, including drugs and biologicals, must represent an expense to the physician or legal entity
billing fir he services or supplies. For example, where a patient purchases a drug and the physician
administers it, the cost of the drug is not covered. However, the administration of the drug, regardless of the
source, is a service that represents an expense to the physician. Therefore, administration of the drug is
payable if the drug would have been covered if the physician purchased it.
B - Direct Personal Supervision
Coverage of services and supplies incident to the professional services of a physician in private practice is
limited to situations in which there is direct physician supervision of auxiliary personnel.
Auxiliary personnel means any individual who is acting under the supervision of a physician, regardless of
whether the individual is an employee, leased employee, or independent contractor of the physician, or of
the legal entity that employs or contracts with the physician. Likewise, the supervising physician may be an
employee, leased employee or independent contractor of the legal entity billing and receiving payment for
the services or supplies.
However, the physician personally furnishing the services or supplies or supervising the auxiliary personnel
furnishing the services or supplies must have a relationship with the legal entity billing and receiving
payment for the services or supplies that satisfies the requirements for valid reassignment. As with the
physician’s personal professional services, the patient’s financial liability for the incident to services or
supplies is to the physician or other legal entity billing and receiving payment for the services or supplies.
Therefore, the incident to services or supplies must represent an expense incurred by the physician or legal
entity billing for the services or supplies.
Thus, where a physician supervises auxiliary personnel to assist him/her in rendering services to patients and
includes the charges for their services in his/her own bills, the services of such personnel are considered
incident to the physician’s service if there is a physician’s service rendered to which the services of such
personnel are an incidental part and there is direct supervision by the physician.
This does not mean, however, that to be considered incident to, each occasion of service by auxiliary
personnel (or the furnishing of a supply) need also always be the occasion of the actual rendition of a
personal professional service by the physician. Such a service or supply could be considered to be incident
to when furnished during a course of treatment where the physician performs an initial service and
subsequent services of a frequency which reflect his/her active participation in and management of the
course of treatment. (However, the direct supervision requirement must still be met with respect to every
nonphysician service.)
Direct supervision in the office setting does not mean that the physician must be present in the same room
with his or her aide. However, the physician must be present in the office suite and immediately available to
provide assistance and direction throughout the time the aide is performing services.
If auxiliary personnel perform services outside the office setting, e.g., in a patient’s home or in an institution
(other than hospital or SNF), their services are covered incident to a physician’s service only if there is
direct supervision by the physician. For example, if a nurse accompanied the physician on house calls and
administered an injection, the nurse’s services are covered. If the same nurse made the calls alone and
administered the injection, the services are not covered (even when billed by the physician) since the
physician is not providing direct supervision. Services provided by auxiliary personnel in an institution (e.g.,
nursing, or convalescent home) present a special problem in determining whether direct physician
supervision exists. The availability of the physician by telephone and the presence of the physician
somewhere in the institution does not constitute direct supervision. (See §70.3 of the Medicare National
Coverage Determinations Manual for instructions used if a physician maintains an office in an institution.)
For hospital patients and for SNF patients who are in a Medicare covered stay, there is no Medicare Part B
coverage of the services of physician-employed auxiliary personnel as services incident to physicians’
services under §1861(s)(2)(A) of the Act. Such services can be covered only under the hospital or SNF
benefit and payment for such services can be made to only the hospital or SNF by a A/B MAC (A). (See
§80 concerning physician supervision of technicians performing diagnostic x-ray procedures in a physician’s
office.)
60.2 - Services of Nonphysician Personnel Furnished Incident To Physician’s Services
(Rev. 1, 10-01-03)
B3-2050.2
In addition to coverage being available for the services of such auxiliary personnel as nurses, technicians,
and therapists when furnished incident to the professional services of a physician (as discussed in §60.1), a
physician may also have the services of certain nonphysician practitioners covered as services incident to a
physician’s professional services. These nonphysician practitioners, who are being licensed by the States
under various programs to assist or act in the place of the physician, include, for example, certified nurse
midwives, clinical psychologists, clinical social workers, physician assistants, nurse practitioners, and
clinical nurse specialists. (See §§150 through 200 for coverage instructions for various allied
health/nonphysician practitioners’ services.)
Services performed by these nonphysician practitioners incident to a physician’s professional services
include not only services ordinarily rendered by a physician’s office staff person (e.g., medical services such
as taking blood pressures and temperatures, giving injections, and changing dressings) but also services
ordinarily performed by the physician such as minor surgery, setting casts or simple fractures, reading x-
rays, and other activities that involve evaluation or treatment of a patient’s condition.
Nonetheless, in order for services of a nonphysician practitioner to be covered as incident to the services of a
physician, the services must meet all of the requirements for coverage specified in §§60 through 60.1. For
example, the services must be an integral, although incidental, part of the physician’s personal professional
services, and they must be performed under the physician’s direct supervision.
A nonphysician practitioner such as a physician assistant or a nurse practitioner may be licensed under State
law to perform a specific medical procedure and may be able (see §§190 or 200, respectively) to perform the
procedure without physician supervision and have the service separately covered and paid for by Medicare
as a physician assistant’s or nurse practitioner’s service. However, in order to have that same service
covered as incident to the services of a physician, it must be performed under the direct supervision of the
physician as an integral part of the physician’s personal in-office service. As explained in §60.1, this does
not mean that each occasion of an incidental service performed by a nonphysician practitioner must always
be the occasion of a service actually rendered by the physician. It does mean that there must have been a
direct, personal, professional service furnished by the physician to initiate the course of treatment of which
the service being performed by the nonphysician practitioner is an incidental part, and there must be
subsequent services by the physician of a frequency that reflects the physician’s continuing active
participation in and management of the course of treatment. In addition, the physician must be physically
present in the same office suite and be immediately available to render assistance if that becomes necessary.
Note also that a physician might render a physician’s service that can be covered even though another
service furnished by a nonphysician practitioner as incident to the physician’s service might not be covered.
For example, an office visit during which the physician diagnoses a medical problem and establishes a
course of treatment could be covered even if, during the same visit, a nonphysician practitioner performs a
noncovered service such as acupuncture.
60.3 - Incident To Physician’s Services in Clinic
(Rev. 1, 10-01-03)
B3-2050.3
Services and supplies incident to a physician’s service in a physician directed clinic or group association are
generally the same as those described above.
A physician directed clinic is one where:
1. A physician (or a number of physicians) is present to perform medical (rather than administrative)
services at all times the clinic is open;
2. Each patient is under the care of a clinic physician; and
3. The nonphysician services are under medical supervision.
In highly organized clinics, particularly those that are departmentalized, direct physician supervision may be
the responsibility of several physicians as opposed to an individual attending physician. In this situation,
medical management of all services provided in the clinic is assured. The physician ordering a particular
service need not be the physician who is supervising the service. Therefore, services performed by auxiliary
personnel and other aides are covered even though they are performed in another department of the clinic.
Supplies provided by the clinic during the course of treatment are also covered. When the auxiliary
personnel perform services outside the clinic premises, the services are covered only if performed under the
direct supervision of a clinic physician. If the clinic refers a patient for auxiliary services performed by
personnel who are not supervised by clinic physicians, such services are not incident to a physician’s
service.
60.4 - Services Incident to a Physician’s Service to Homebound Patients Under General
Physician Supervision
(Rev. 1, 10-01-03)
B3-2051
A. When Covered
In some medically underserved areas there are only a few physicians available to provide services over
broad geographic areas or to a large patient population. The lack of medical personnel (and, in many
instances, a home health agency servicing the area) significantly reduces the availability of certain medical
services to homebound patients. Some physicians and physician-directed clinics, therefore, call upon nurses
and other paramedical personnel to provide these services under general (rather than direct) supervision. In
some areas, such practice has tended to become the accepted method of delivery of these services.
The Senate Finance Committee Report accompanying the 1972 Amendments to the Act recommended that
the direct supervision requirement of the “incident to” provision be modified to provide coverage for
services provided in this manner.
Accordingly, to permit coverage of certain of these services, the direct supervision criterion in §60.2 above
is not applicable to individual or intermittent services outlined in this section when they are performed by
personnel meeting any pertinent State requirements (e.g., a nurse, technician, or physician extender) and
where the criteria listed below also are met:
1 The patient is homebound; i.e., confined to his or her home (see §60.4.1 for the definition of a
“homebound” patient and §110.1 (D) for the definition of patient’s “place of residence.”
2 The service is an integral part of the physician’s service to the patient (the patient must be one the
physician is treating), and is performed under general physician supervision by employees of the
physician or clinic. General supervision means that the physician need not be physically present at
the patient’s place of residence when the service is performed; however, the service must be
performed under his or her overall supervision and control.
The physician orders the service(s) to be performed, and contact is maintained between the nurse or
other employee and the physician, e.g., the employee contacts the physician directly if additional
instructions are needed, and the physician must retain professional responsibility for the service. All
other “incident to” requirements must be met (see §§60-60.4).
3 The services are included in the physician’s/clinic’s bill, and the physician or clinic has incurred an
expense for them (see §60.2).
4 The services of the paramedical are required for the patient’s care; that is, they are reasonable and
necessary as defined in the Medicare Benefit Policy Manual, Chapter 16, “General Exclusions from
Coverage,” §20.
5 When the service can be furnished by an HHA in the local area, it cannot be covered when furnished
by a physician/clinic to a homebound patient under this provision, except as described in §60.4.C.
B. Covered Services
Where the requirements in §60.4.A are met, the direct supervision requirement in §60.2 is not applicable to
the following services:
1. Injections;
2. Venipuncture;
3. EKGs;
4. Therapeutic exercises;
5. Insertion and sterile irrigation of a catheter;
6. Changing of catheters and collection of catheterized specimen for urinalysis and culture;
7. Dressing changes, e.g., the most common chronic conditions that may need dressing changes are
decubitus care and gangrene;
8. Replacement and/or insertion of nasogastric tubes;
9. Removal of fecal impaction, including enemas;
10. Sputum collection for gram stain and culture, and possible acid-fast and/or fungal stain and culture;
11. Paraffin bath therapy for hands and/or feet in rheumatoid arthritis or osteoarthritis;
12. Teaching and training the patient for:
a. The care of colostomy and ileostomy;
b. The care of permanent tracheostomy;
c. Testing urine and care of the feet (diabetic patients only); and
d. Blood pressure monitoring.
Teaching and training services (also referred to as educational services) can be covered only where they
provide knowledge essential for the chronically ill patient’s participation in his or her own treatment and
only where they can be reasonably related to such treatment or diagnosis. Educational services that provide
more elaborate instruction than is necessary to achieve the required level of patient education are not
covered. After essential information has been provided, the patient should be relied upon to obtain
additional information on his or her own.
C. Relation to Home Health Benefits
This coverage should not be considered as an alternative to home health benefits where there is a
participating home health agency in the area which could provide the needed services on a timely basis. For
example, two of the three services initially included under this coverage - injections and venipuncture - are
skilled nursing services that could be covered as home health services (EKG is not a covered Home Health
Agency (HHA) service) if the patient is eligible for home health benefits and there is a home health agency
available. Thus, postpayment review of these claims will include measures to assure that physicians and
clinics do not provide a substantial number of services under this coverage when they could otherwise have
been performed by a home health agency.
In these circumstances, the physician or clinic is expected to assist the patient in obtaining such skilled
services together with the other home health services (such as aide services). However, HHA services are
not considered available where the HHA cannot respond on a timely basis or where the physician could not
have foreseen that intermittent services would be needed.
Refer to the Medicare Claims Processing Manual, Chapter 10, “Home Health Agency Billing,” for a more in
depth discussion of home health services.
60.4.1 - Definition of Homebound Patient Under the Medicare Home Health (HH)
Benefit
(Rev. 192, Issued: 08-01-14, Effective: 09-02-14, Implementation: 09-02-14)
This definition applies to homebound for purposes of the Medicare home health benefit.
For a patient to be eligible to receive covered home health services, the law requires that a physician certify
in all cases that the patient is confined to his/her home. For purposes of the statute, an individual shall be
considered “confined to the home” (homebound) if the following two criteria are met:
1. Criteria-One:
The patient must either:
- Because of illness or injury, need the aid of supportive devices such as crutches, canes,
wheelchairs, and walkers; the use of special transportation; or the assistance of another person in
order to leave their place of residence
OR
- Have a condition such that leaving his or her home is medically contraindicated.
If the patient meets one of the Criteria-One conditions, then the patient must ALSO meet two additional
requirements defined in Criteria-Two below.
2. Criteria-Two:
- There must exist a normal inability to leave home;
AND
- Leaving home must require a considerable and taxing effort.
If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the
absences from the home are infrequent or for periods of relatively short duration, or are attributable to the
need to receive health care treatment. Absences attributable to the need to receive health care treatment
include, but are not limited to:
• Attendance at adult day centers to receive medical care;
• Ongoing receipt of outpatient kidney dialysis; or
• The receipt of outpatient chemotherapy or radiation therapy.
Any absence of an individual from the home attributable to the need to receive health care treatment,
including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment
in an adult day-care program that is licensed or certified by a State, or accredited to furnish adult day-care
services in a state, shall not disqualify an individual from being considered to be confined to his home. Any
other absence of an individual from the home shall not so disqualify an individual if the absence is of an
infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the
purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration. It
is expected that in most instances, absences from the home that occur will be for the purpose of receiving
health care treatment. However, occasional absences from the home for nonmedical purposes, e.g., an
occasional trip to the barber, a walk around the block or a drive, attendance at a family reunion, funeral,
graduation, or other infrequent or unique event would not necessitate a finding that the patient is not
homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do
not indicate that the patient has the capacity to obtain the health care provided outside rather than in the
home.
Some examples of homebound patients that illustrate the factors used to determine whether a homebound
condition exists would be:
• A patient paralyzed from a stroke who is confined to a wheelchair or requires the aid of crutches in
order to walk;
• A patient who is blind or senile and requires the assistance of another person in leaving his or her
place of residence;
• A patient who has lost the use of the upper extremities and, therefore, is unable to open doors, use
handrails on stairways, etc., requires the assistance of another individual to leave his or her place of
residence;
• A patient in the late stages of ALS or neurodegenerative disabilities. In determining whether the
patient has the general inability to leave the home and leaves the home only infrequently or for
periods of short duration, it is necessary to look at the patient’s condition over a period of time rather
than for short periods within the home health stay. For example, a patient may leave the home
(under the conditions described above, e.g., with severe and taxing effort, with the assistance of
others) more frequently during a short period when, for example, the presence of visiting relatives
provides a unique opportunity for such absences, than is normally the case. So long as the patient’s
overall condition and experience is such that he or she meets these qualifications, he or she should be
considered confined to the home.
• A patient who has just returned from a hospital stay involving surgery who may be suffering from
resultant weakness and pain and, therefore, his or her actions may be restricted by the physician to
certain specified and limited activities such as getting out of bed only for a specified period of time,
or walking stairs only once a day, etc.;
• A patient with arteriosclerotic heart disease of such severity that the beneficiary must avoid all stress
and physical activity; and
• A patient with a psychiatric illness that is manifested in part by a refusal to leave home or is of such
a nature that it would not be considered safe for the patient to leave home unattended, even if he or
she had no physical limitations.
The aged person who does not often travel from home because of feebleness and insecurity brought on by
advanced age would not be considered confined to the home for purposes of this reimbursement unless they
meet one of the above conditions above.
70 - Sleep Disorder Clinics
(Rev. 1, 10-01-03)
B3-2055
Sleep disorder clinics are facilities in which certain conditions are diagnosed through the study of sleep.
Such clinics are for diagnosis, therapy, and research. Sleep disorder clinics may provide some diagnostic or
therapeutic services, which are covered under Medicare. These clinics may be affiliated either with a
hospital or a freestanding facility. Whether a clinic is hospital-affiliated or freestanding, coverage for
diagnostic services under some circumstances is covered under provisions of the law different from those for
coverage of therapeutic services.
A. Criteria for Coverage of Diagnostic Tests
All reasonable and necessary diagnostic tests given for the medical conditions listed in subsection B are
covered when the following criteria are met:
• The clinic is either affiliated with a hospital or is under the direction and control of physicians.
Diagnostic testing routinely performed in sleep disorder clinics may be covered even in the absence
of direct supervision by a physician;
• Patients are referred to the sleep disorder clinic by their attending physicians, and the clinic
maintains a record of the attending physician’s orders; and
• The need for diagnostic testing is confirmed by medical evidence, e.g., physician examinations and
laboratory tests.
Diagnostic testing that is duplicative of previous testing done by the attending physician to the extent the
results are still pertinent is not covered because it is not reasonable and necessary under §1862(a)(1)(A) of
the Act.
B. Medical Conditions for Which Testing is Covered
Diagnostic testing is covered only if the patient has the symptoms or complaints of one of the conditions
listed below. Most of the patients who undergo the diagnostic testing are not considered inpatients, although
they may come to the facility in the evening for testing and then leave after testing is over. The overnight
stay is considered an integral part of these tests.
1. Narcolepsy - This term refers to a syndrome that is characterized by abnormal sleep tendencies, e.g.,
excessive daytime sleepiness or disturbed nocturnal sleep. Related diagnostic testing is covered if the
patient has inappropriate sleep episodes or attacks (e.g., while driving, in the middle of a meal, in the middle
of a conversation), amnesiac episodes, or continuous disabling drowsiness. The sleep disorder clinic must
submit documentation that this condition is severe enough to interfere with the patient’s well being and
health before Medicare benefits may be provided for diagnostic testing. Ordinarily, a diagnosis of
narcolepsy can be confirmed by three sleep naps. If more than three sleep naps are claimed, the A/B MAC
(B) will require persuasive medical evidence justifying the medical necessity for the additional test(s). It
will use HCPCS procedure codes 95828 and 95805.
2. Sleep Apnea - This is a potentially lethal condition where the patient stops breathing during sleep.
Three types of sleep apnea have been described (central, obstructive, and mixed). The nature of the apnea
episodes can be documented by appropriate diagnostic testing. Ordinarily, a single polysomnogram and
electroencephalogram (EEG) can diagnose sleep apnea. If more than one such testing session is claimed, the
A/B MAC (B) will require persuasive medical evidence justifying the medical necessity for the additional
tests. It will use HCPCS procedure codes 95807, 95810, and 95822.
3. Impotence - Diagnostic nocturnal penile tumescence testing may be covered, under limited
circumstances, to determine whether erectile impotence in men is organic or psychogenic. Although
impotence is not a sleep disorder, the nature of the testing requires that it be performed during sleep. The
tests ordinarily are covered only where necessary to confirm the treatment to be given (surgical, medical, or
psychotherapeutic). Ordinarily, a diagnosis may be determined by two nights of diagnostic testing. If more
than two nights of testing are claimed, the A/B MAC (B) will require persuasive medical evidence justifying
the medical necessity for the additional tests. It will have its medical staff review questionable cases to
ensure that the tests are reasonable and necessary for the individual. It will use HCPCS procedure code
54250. (See the Medicare National Coverage Determinations Manual, Chapter 1, for policy on coverage of
diagnosis and treatment of impotence.)
4. Parasomnia - Parasomnias are a group of conditions that represent undesirable or unpleasant
occurrences during sleep. Behavior during these times can often lead to damage to the surroundings and
injury to the patient or to others. Parasomnia may include conditions such as sleepwalking, sleep terrors,
and rapid eye movement (REM) sleep behavior disorders. In many of these cases, the nature of these
conditions may be established by careful clinical evaluation. Suspected seizure disorders as possible cause
of the parasomnia are appropriately evaluated by standard or prolonged sleep EEG studies. In cases where
seizure disorders have been ruled out and in cases that present a history of repeated violent or injurious
episodes during sleep, polysomnography may be useful in providing a diagnostic classification or prognosis.
The A/B MAC (B) must use HCPCS procedure codes 95807, 95810, and/or 95822.
C. Polysomnography for Chronic Insomnia Is Not Covered.
Evidence at the present time is not convincing that polysomnography in a sleep disorder clinic for chronic
insomnia provides definitive diagnostic data or that such information is useful in patient treatment or is
associated with improved clinical outcome. The use of polysomnography for diagnosis of patients with
chronic insomnia is not covered under Medicare because it is not reasonable and necessary under
§1862(a)(1)(A) of the Act.
D. Coverage of Therapeutic Services.
Sleep disorder clinics may at times render therapeutic as well as diagnostic services. Therapeutic services
may be covered in a hospital outpatient setting or in a freestanding facility provided they meet the pertinent
requirements for the particular type of services and are reasonable and necessary for the patient, and are
performed under the direct supervision of a physician.
80 - Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic
Tests
(Rev. 11901; Issued: 03-16-23; Effective: 01-01-21; Implementation: 05-17-23)
This section describes the levels of physician supervision required for furnishing the technical component of
diagnostic tests for a Medicare beneficiary who is not a hospital inpatient. For hospital outpatient diagnostic
services, the supervision levels assigned to each CPT or Level II HCPCS code in the Medicare Physician
Fee Schedule Relative
Value File that is updated quarterly, apply as described below. For more information, see Chapter 6
(Hospital Services Covered Under Part B), §20.4 (Outpatient Diagnostic Services).
Section 410.32(b) of the Code of Federal Regulations (CFR) requires that diagnostic tests covered under
§1861(s)(3) of the Act and payable under the physician fee schedule, with certain exceptions listed in the
regulation, have to be performed under the supervision of an individual meeting the definition of a physician
(§1861(r) of the Act) to be considered reasonable and necessary and, therefore, covered under Medicare.
However, effective January 1, 2021, the basic rule at 42 CFR 410.32(b)(1) requires that diagnostic tests
covered under §1861(s)(3) of the Act and payable under the physician fee schedule must be furnished under
the appropriate level of supervision by a physician as defined in §1861(r) of the Act or, to the extent that
they are authorized to do so under their scope of practice and applicable State law, by a nurse practitioner,
clinical nurse specialist, certified nurse-midwife, certified registered nurse anesthetist or physician assistant.
Services furnished without the required level of supervision are not reasonable and necessary.
The regulation defines these levels of supervision for diagnostic tests as follows:
General Supervision - means the procedure is furnished under the physician’s overall direction and control,
but the physician’s presence is not required during the performance of the procedure. Under general
supervision, the training of the nonphysician personnel who actually performs the diagnostic procedure and
the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.
Direct Supervision - in the office setting means the physician (or other supervising practitioner) must be
present in the office suite and immediately available to furnish assistance and direction throughout the
performance of the procedure. It does not mean that the physician (or other supervising practitioner) must
be present in the room when the procedure is performed.
Personal Supervision - means a physician must be in attendance in the room during the performance of the
procedure.
One of the following numerical levels is assigned to each CPT or HCPCS code in the Medicare Physician
Fee Schedule Database:
0 Procedure is not a diagnostic test or procedure is a diagnostic test which is not subject to the
physician supervision policy.
1 Procedure must be performed under the general supervision of a physician.
2 Procedure must be performed under the direct supervision of a physician.
3 Procedure must be performed under the personal supervision of a physician. (For services rendered
on or after 01/01/2019 diagnostic imaging procedures performed by a Registered Radiologist Assistant
(RRA) who is certified and registered by the American Registry of Radiologic Technologists (ARRT) or
a Radiology Practitioner Assistant (RPA) who is certified by the Certification Board for Radiology
Practitioner Assistants (CBRPA), and is authorized to furnish the procedure under state law, may be
performed under direct supervision).
4 Physician supervision policy does not apply when procedure is furnished by a qualified, independent
psychologist or a clinical psychologist or furnished under the general supervision of a clinical
psychologist; otherwise must be performed under the general supervision of a physician.
5 Physician supervision policy does not apply when procedure is furnished by a qualified audiologist;
otherwise must be performed under the general supervision of a
physician.
6 Procedure must be performed by a physician or by a physical therapist (PT) who is certified by the
American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiologic clinical
specialist and is permitted to provide the procedure under State law.
6a Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may supervise
another PT but only the PT with ABPTS certification may bill.
7a Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may supervise
another PT but only the PT with ABPTS certification may bill.
9 Concept does not apply.
21 Procedure must be performed by a technician with certification under general supervision of a
physician; otherwise must be performed under direct supervision of a physician.
22 Procedure may be performed by a technician with on-line real-time contact with physician.
66 Procedure must be performed by a physician or by a PT with ABPTS certification and certification in this
specific procedure.
77 Procedure must be performed by a PT with ABPTS certification or by a PT without certification under
direct supervision of a physician, or by a technician with certification under general supervision of a
physician.
When nurse practitioners, clinical nurse specialists, and physician assistants personally perform diagnostic
tests as provided under §1861(s)(2)(K) of the Act, the supervision requirements under §1861(s)(3) of the Act
and under 42 CFR 410.32 do not apply. Rather, these practitioners are authorized to personally perform
diagnostic tests under the supervision requirements applicable to their practitioner benefit category pursuant
to State scope of practice laws and under the applicable State requirements.
Because the diagnostic tests benefit category set forth in §1861(s)(3) of the Act is separately enumerated and
distinct from the “incident to” benefit category set forth in §1861(s)(2)(A) of the Act, diagnostic tests cannot
be billed to the Medicare program as “incident to” services. Accordingly, the supervision requirements
under the “incident to” benefit category are not applicable to the diagnostic tests benefit category.
80.1 - Clinical Laboratory Services
(Rev. 79; Issued: 10-19-07; Effective: 01-01-03; Implementation: 11-19-07)
Section 1833 and 1861 of the Act provides for payment of clinical laboratory services under Medicare Part
B. Clinical laboratory services involve the biological, microbiological, serological, chemical,
immunohematological, hematological, biophysical, cytological, pathological, or other examination of
materials derived from the human body for the diagnosis, prevention, or treatment of a disease or assessment
of a medical condition. Laboratory services must meet all applicable requirements of the Clinical
Laboratory Improvement Amendments of 1988 (CLIA), as set forth at 42 CFR part 493. Section
1862(a)(1)(A) of the Act provides that Medicare payment may not be made for services that are not
reasonable and necessary. Clinical laboratory services must be ordered and used promptly by the physician
who is treating the beneficiary as described in 42 CFR 410.32(a), or by a qualified nonphysician
practitioner, as described in 42 CFR 410.32(a)(3).
See section 80.6 of this manual for related physician ordering instructions.
See the Medicare Claims Processing Manual Chapter 16 for related claims processing instructions.
80.1.1 - Certification Changes
(Rev. 1, 10-01-03)
B3-2070.1.E
Each page of the lists of approved specialties also includes a column “Certification Changed” in which the
following codes are used:
“C” indicates a change in the laboratory’s approved certification since the preceding listing.
“A” discloses an accretion.
“TERM” - Laboratory not approved for payment after the indicated date which follows the code. The
reason for termination also is given in the following codes:
1. Involuntary termination - no longer meets requirements
2. Voluntary withdrawal
3. Laboratory closed, merged with other interests, or organizational change
4. Ownership change with new ownership participating under different name
5. Ownership change with new owner not participating
6. Change in ownership - new provider number assigned
7. Involuntary termination - failure to abide by agreement
8. Former “emergency” hospital now fully participating
80.1.2 - A/B MAC (B) Contacts With Independent Clinical Laboratories
(Rev. 1, 10-01-03)
B3-2070.1.F
An important role of the A/B MAC (B) is as a communicant of necessary information to independent
clinical laboratories. Experience has shown that the failure to inform laboratories of Medicare regulations
and claims processing procedures may have an adverse effect on prosecution of laboratories suspected of
fraudulent activities with respect to tests performed by, or billed on behalf of, independent laboratories.
United States Attorneys often have to prosecute under a handicap or may simply refuse to prosecute cases
where there is no evidence that a laboratory has been specifically informed of Medicare regulations and
claims processing procedures.
A/B MACs (B) must follow the Provider Education and Training (PET) guidelines to assure that
laboratories are aware of Medicare regulations and the A/B MAC (B’s) policy when any changes are made
in coverage policy or claims processing procedures. The PET guidelines require A/B MACs (B) to use
various methods of communication (such as print, Internet, face-to-face instruction). Newsletters/bulletins
that contain program and billing information must be produced at least quarterly and posted on the A/B
MAC (B) Web site where duplicate copies may be obtained.
Some items which should be communicated to laboratories and responsibilities that laboratories are required
to perform are:
• The requirements to have the same fee schedule for Medicare and private patients;
• To specify whether the tests are manual or automated;
• To document fully the medical necessity for pickup of specimens from a skilled nursing facility or a
beneficiary’s home, and
• In cases when a laboratory service is referred from one independent laboratory to another
independent laboratory, to identify the laboratory actually performing the test.
Additionally, when A/B MAC (B) professional relations representatives make personal contacts with
particular laboratories, the representative should prepare and retain reports of contact indicating dates,
persons present, and issues discussed. Finally, A/B MACs (B) should inform independent laboratories that
the Medicare National Coverage Determinations Manual as well as other guidelines contained in the manual
for determining medical necessity are on the Web site. A/B MACs (B) should also publish local guidelines
on its Web site; the A/B MAC (B) should not duplicate national instructions here. Timely paper or
electronic communications concerning the Internet publications to independent laboratories new to the A/B
MAC (B)’s service area are essential.
80.1.3 - Independent Laboratory Service to a Patient in the Patient’s Home or an
Institution
(Rev. 1, 10-01-03)
B3-2070.1.G
Where it is medically necessary for an independent laboratory to visit a patient to obtain a specimen, the
service would be covered in the following circumstances:
1. Patient Confined to Home
If a patient is confined to the home or other place of residence used as his or her home (see §60.4.1 for the
definition of a “homebound patient”), medical necessity would exist (e.g., where a laboratory technician
draws a blood specimen). However, where the specimen is a type which would require only the services of
a messenger and would not require the skills of a laboratory technician, e.g., urine or sputum, a specimen
pickup service would not be considered medically necessary.
2. Place of Residence is an Institution
Medical necessity could also exist where the patient’s place of residence is an institution, including a skilled
nursing facility that does not perform venipunctures. This would apply even though the institution meets the
basic definition of a skilled nursing facility and would not ordinarily be considered a beneficiary’s home.
(This policy is intended for independent laboratories only and does not expand the range of coverage of
services to homebound patients under the incident to provision.) A trip by an independent laboratory
technician to a facility (other than a hospital) for the purpose of performing a venipuncture is considered
medically necessary only if:
a. The patient was confined to the facility; and
b. The facility did not have on duty personnel qualified to perform this service.
When facility personnel actually obtained and prepared the specimens for the independent laboratory to pick
them up, the laboratory provides this pickup service as a service to the facility in the same manner as it does
for physicians.
80.2 - Psychological Tests and Neuropsychological Tests
(Rev. 85, Issued: 02-29-08, Effective: 01-01-06, Implementation: 12-28-06)
Medicare Part B coverage of psychological tests and neuropsychological tests is authorized under section
1861(s)(3) of the Social Security Act. Payment for psychological and neuropsychological tests is authorized
under section 1842(b)(2)(A) of the Social Security Act. The payment amounts for the new psychological
and neuropsychological tests (CPT codes 96102, 96103, 96119 and 96120) that are effective January 1,
2006, and are billed for tests administered by a technician or a computer reflect a site of service payment
differential for the facility and non-facility settings. Additionally, there is no authorization for payment for
diagnostic tests when performed on an “incident to” basis.
Under the diagnostic tests provision, all diagnostic tests are assigned a certain level of supervision.
Generally, regulations governing the diagnostic tests provision require that only physicians can provide the
assigned level of supervision for diagnostic tests. However, there is a regulatory exception to the
supervision requirement for diagnostic psychological and neuropsychological tests in terms of who can
provide the supervision. That is, regulations allow a clinical psychologist (CP) or a physician to perform the
general supervision assigned to diagnostic psychological and neuropsychological tests.
In addition, nonphysician practitioners such as nurse practitioners (NPs), clinical nurse specialists (CNSs)
and physician assistants (PAs) who personally perform diagnostic psychological and neuropsychological
tests are excluded from having to perform these tests under the general supervision of a physician or a CP.
Rather, NPs and CNSs must perform such tests under the requirements of their respective benefit instead of
the requirements for diagnostic psychological and neuropsychological tests. Accordingly, NPs and CNSs
must perform tests in collaboration (as defined under Medicare law at section 1861(aa)(6) of the Act) with a
physician. PAs perform tests under the general supervision of a physician as required for services furnished
under the PA benefit.
Furthermore, physical therapists (PTs), occupational therapists (OTs) and speech language pathologists
(SLPs) are authorized to bill three test codes as “sometimes therapy” codes. Specifically, CPT codes 96105,
96110 and 96111 may be performed by these therapists. However, when PTs, OTs and SLPs perform these
three tests, they must be performed under the general supervision of a physician or a CP.
Who May Bill for Diagnostic Psychological and Neuropsychological Tests
• CPs - see qualifications under chapter 15, section 160 of the Benefit Policy Manual, Pub. 100-02.
• NPs -to the extent authorized under State scope of practice. See qualifications under chapter 15,
section 200 of the Benefit Policy Manual, Pub. 100-02.
• CNSs -to the extent authorized under State scope of practice. See qualifications under chapter 15,
section 210 of the Benefit Policy Manual, Pub. 100-02.
• PAs - to the extent authorized under State scope of practice. See qualifications under chapter 15,
section 190 of the Benefit Policy Manual, Pub. 100-02.
• Independently Practicing Psychologists (IPPs)
• PTs, OTs and SLPs - see qualifications under chapter 15, sections 220-230.6 of the Benefit Policy
Manual, Pub. 100-02.
Psychological and neuropsychological tests performed by a psychologist (who is not a CP) practicing
independently of an institution, agency, or physician’s office are covered when a physician orders such tests.
An IPP is any psychologist who is licensed or certified to practice psychology in the State or jurisdiction
where furnishing services or, if the jurisdiction does not issue licenses, if provided by any practicing
psychologist. (It is CMS’ understanding that all States, the District of Columbia, and Puerto Rico license
psychologists, but that some trust territories do not. Examples of psychologists, other than CPs, whose
psychological and neuropsychological tests are covered under the diagnostic tests provision include, but are
not limited to, educational psychologists and counseling psychologists.)
The A/B MAC (B) must secure from the appropriate State agency a current listing of psychologists holding
the required credentials to determine whether the tests of a particular IPP are covered under Part B in States
that have statutory licensure or certification. In States or territories that lack statutory licensing or
certification, the A/B MAC (B) checks individual qualifications before provider numbers are issued.
Possible reference sources are the national directory of membership of the American Psychological
Association, which provides data about the educational background of individuals and indicates which
members are board-certified, the records and directories of the State or territorial psychological association,
and the National Register of Health Service Providers. If qualification is dependent on a doctoral degree
from a currently accredited program, the A/B MAC (B) verifies the date of accreditation of the school
involved, since such accreditation is not retroactive. If the listed reference sources do not provide enough
information (e.g., the psychologist is not a member of one of these sources), the A/B MAC (B) contacts the
psychologist personally for the required information. Generally, A/B MACs (B) maintain a continuing list
of psychologists whose qualifications have been verified.
NOTE: When diagnostic psychological tests are performed by a psychologist who is not practicing
independently, but is on the staff of an institution, agency, or clinic, that entity bills for the psychological
tests.
The A/B MAC (B) considers psychologists as practicing independently when:
• They render services on their own responsibility, free of the administrative and professional control
of an employer such as a physician, institution or agency;
• The persons they treat are their own patients; and
• They have the right to bill directly, collect and retain the fee for their services.
A psychologist practicing in an office located in an institution may be considered an independently
practicing psychologist when both of the following conditions exist:
• The office is confined to a separately-identified part of the facility which is used solely as the
psychologist’s office and cannot be construed as extending throughout the entire institution; and
• The psychologist conducts a private practice, i.e., services are rendered to patients from outside the
institution as well as to institutional patients.
Payment for Diagnostic Psychological and Neuropsychological Tests
Expenses for diagnostic psychological and neuropsychological tests are not subject to the outpatient mental
health treatment limitation, that is, the payment limitation on treatment services for mental, psychoneurotic
and personality disorders as authorized under Section 1833(c) of the Act. The payment amount for the new
psychological and neuropsychological tests (CPT codes 96102, 96103, 96119 and 96120) that are billed for
tests performed by a technician or a computer reflect a site of service payment differential for the facility
and non-facility settings. CPs, NPs, CNSs and PAs are required by law to accept assigned payment for
psychological and neuropsychological tests. However, while IPPs are not required by law to accept
assigned payment for these tests, they must report the name and address of the physician who ordered the
test on the claim form when billing for tests.
CPT Codes for Diagnostic Psychological and Neuropsychological Tests
The range of CPT codes used to report psychological and neuropsychological tests is 96101-96120. CPT
codes 96101, 96102, 96103, 96105, 96110, and 96111 are appropriate for use when billing for psychological
tests. CPT codes 96116, 96118, 96119 and 96120 are appropriate for use when billing for
neuropsychological tests.
All of the tests under this CPT code range 96101-96120 are indicated as active codes under the physician fee
schedule database and are covered if medically necessary.
Payment and Billing Guidelines for Psychological and Neuropsychological Tests
The technician and computer CPT codes for psychological and neuropsychological tests include practice
expense, malpractice expense and professional work relative value units. Accordingly, CPT psychological
test code 96101 should not be paid when billed for the same tests or services performed under psychological
test codes 96102 or 96103. CPT neuropsychological test code 96118 should not be paid when billed for the
same tests or services performed under neuropsychological test codes 96119 or 96120. However, CPT
codes 96101 and 96118 can be paid separately on the rare occasion when billed on the same date of service
for different and separate tests from 96102, 96103, 96119 and 96120.
Under the physician fee schedule, there is no payment for services performed by students or trainees.
Accordingly, Medicare does not pay for services represented by CPT codes 96102 and 96119 when
performed by a student or a trainee. However, the presence of a student or a trainee while the test is being
administered does not prevent a physician, CP, IPP, NP, CNS or PA from performing and being paid for the
psychological test under 96102 or the neuropsychological test under 96119.
80.3 - Audiology Services
(Rev. 132, Issued: 09-03-10, Effective: 09-30-10, Implementation: 09-30-10)
References.
1861(ll)(3) of the Social Security Act for the definition of audiology services.
1861(ll)(4)(B) of the Social Security Act for qualifications of audiologists.
42 CFR 410.32(b) for the physician supervision requirements for diagnostic tests.
Pub. 100-04, chapter 12, section 30.3 for coding and billing information related to audiological services
and aural rehabilitation.
Pub. 100-02, chapter 15, sections 220 and 230 for the physical therapy and speech-language pathology
policies relative to aural rehabilitation and balance, section 60 for services incident to a physician’s
service, and section 80.6 for policies relevant to ordering for diagnostic tests.
Pub. 100-02, chapter 16, section 100 for hearing aid policies.
A list of audiology services is found at: www.cms.gov/therapyservices.
A. Benefit.
Hearing and balance assessment services are generally covered as “other diagnostic tests” under section
1861(s)(3) of the Social Security Act. Hearing and balance assessment services furnished to an outpatient of
a hospital are covered as “diagnostic services” under section 1861(s)(2)(C).
As defined in the Social Security Act, section 1861(ll)(3), the term “audiology services” specifically means
such hearing and balance assessment services furnished by a qualified audiologist as the audiologist is
legally authorized to perform under State law (or the State regulatory mechanism provided by State law), as
would otherwise be covered if furnished by a physician.
Herein after in this section, hearing and balance assessment services are termed “audiology services,”
regardless of whether they are furnished by an audiologist, physician, nonphysician practitioner (NPP), or
hospital.
Because audiology services are diagnostic tests, when furnished by a physician in an office or hospital
outpatient department, they must be furnished under the appropriate level of supervision of a physician as
established in 42 CFR 410.32(b)(1) and 410.28(e). However, as specified in 42 CFR 410.32(b)(2)(ii) or (v),
respectively, they are excepted from physician supervision when they are personally furnished by a qualified
audiologist or performed by a nurse practitioner or clinical nurse specialist authorized to perform the tests
under applicable State laws.
Audiological diagnostic testing refers to tests of the audiological and vestibular systems, e.g., hearing,
balance, auditory processing, tinnitus and diagnostic programming of certain prosthetic devices, performed
by qualified audiologists.
Audiological diagnostic tests are not covered under the benefit for services incident to a physician’s service
(described in Pub. 100-02, chapter 15, section 60), because they have their own benefit as “other diagnostic
tests”. See Pub. 100-04, chapter 13 for general diagnostic test policies.
Audiology services, like all other services, should be reported under the most specific HCPCS code that
describes the service that was furnished and in accordance with all CPT guidance and Medicare national and
MAC instructions.
B. Orders.
Audiology tests are covered as “other diagnostic tests” under section 1861(s)(3) or 1861(s)(2)(C) of the Act
in the physician’s office or hospital outpatient settings, respectively, when a physician (or an NPP, as
applicable) orders such testing for the purpose of obtaining information necessary for the physician’s
diagnostic medical evaluation or to determine the appropriate medical or surgical treatment of a hearing
deficit or related medical problem. See section 80.6 of this chapter for policies regarding the ordering of
diagnostic tests.
If a beneficiary undergoes diagnostic testing performed by an audiologist without a physician order, the tests
are not covered even if the audiologist discovers a pathologic condition.
When a qualified physician orders a qualified technician (see definition in subsection D of this section) to
furnish an appropriate audiology service, that order must specify which test is to be furnished by the
technician under the direct supervision of a physician. Only that test may be provided on that order by the
technician.
When the qualified physician or NPP orders diagnostic audiology services furnished by an audiologist
without naming specific tests, the audiologist may select the appropriate battery of tests.
C. Coverage and Payment for Audiology Services.
Diagnostic services furnished by a qualified audiologist meeting the requirements in section 80.3.1 of this
chapter or physicians and NPPs as described in section 80.6 are covered and payable under the MPFS as
“other diagnostic tests.”
Services furnished in a hospital outpatient department are covered and payable under the hospital Outpatient
Prospective Payment System (OPPS) or other payment methodology applicable to the provider furnishing
the services.
Coverage and, therefore, payment for audiological diagnostic tests is determined by the reason the tests were
performed, rather than by the diagnosis or the patient’s condition.
Under any Medicare payment system, payment for audiological diagnostic tests is not allowed by virtue of
their exclusion from coverage in section 1862(a)(7) of the Social Security Act when:
• The type and severity of the current hearing, tinnitus or balance status needed to determine the
appropriate medical or surgical treatment is known to the physician before the test; or
• The test was ordered for the specific purpose of fitting or modifying a hearing aid.
Payment of audiological diagnostic tests is allowed for other reasons and is not limited, for example, by:
• Any information resulting from the test, for example:
ο Confirmation of a prior diagnosis;
ο Post-evaluation diagnoses; or
ο Treatment provided after diagnosis, including hearing aids, or
• The type of evaluation or treatment the physician anticipates before the diagnostic test; or
• Timing of reevaluation. Reevaluation is appropriate at a schedule dictated by the ordering
physician when the information provided by the diagnostic test is required, for example, to
determine changes in hearing, to evaluate the appropriate medical or surgical treatment or to
evaluate the results of treatment. For example, reevaluation may be appropriate, even when the
evaluation was recent, in cases where the hearing loss, balance, or tinnitus may be progressive or
fluctuating, the patient or caregiver complains of new symptoms, or treatment (such as
medication or surgery) may have changed the patient’s audiological condition with or without
awareness by the patient.
Examples of appropriate reasons for ordering audiological diagnostic tests that could be covered include, but
are not limited to:
• Evaluation of suspected change in hearing, tinnitus, or balance;
• Evaluation of the cause of disorders of hearing, tinnitus, or balance;
• Determination of the effect of medication, surgery, or other treatment;
• Reevaluation to follow-up changes in hearing, tinnitus, or balance that may be caused by established
diagnoses that place the patient at probable risk for a change in status including, but not limited to:
otosclerosis, atelectatic tympanic membrane, tympanosclerosis, cholesteatoma, resolving middle ear
infection, Meniére’s disease, sudden idiopathic sensorineural hearing loss, autoimmune inner ear
disease, acoustic neuroma, demyelinating diseases, ototoxicity secondary to medications, or genetic
vascular and viral conditions;
• Failure of a screening test (although the screening test is not covered);
• Diagnostic analysis of cochlear or brainstem implant and programming; and
• Audiology diagnostic tests before and periodically after implantation of auditory prosthetic devices.
If a physician refers a beneficiary to an audiologist for testing related to signs or symptoms associated with
hearing loss, balance disorder, tinnitus, ear disease, or ear injury, the audiologist’s diagnostic testing services
should be covered even if the only outcome is the prescription of a hearing aid.
D. Individuals Who Furnish Audiology Tests.
1. Qualified Professionals. See section 80.3.1 of this chapter for the qualifications of audiologists. See
section 80.6 of this chapter for the qualifications of physicians and NPPs who may furnish diagnostic tests.
2. Qualified Technicians or Other Qualified Staff. References to technicians in this section include other
qualified clinical staff. The qualifications for technicians vary locally and may also depend on the type of
test, the patient, and the level of participation of the physician who is directly supervising the test.
Therefore, an individual must meet qualifications appropriate to the service furnished as determined by the
MAC to whom the claim is billed. If it is necessary to determine whether the individual who furnished the
labor for appropriate audiology services is qualified, MACs may request verification of any relevant
education and training that has been completed by the technician, which shall be available in the records of
the clinic or facility.
Depending on the qualifications determined by the MAC, individuals who are also hearing instrument
specialists, students of audiology, or other health care professionals may furnish the labor for appropriate
audiology services under direct physician supervision when these services are billed by physicians or
hospital outpatient departments.
E. Documentation for Audiology Services.
1. Documentation for Orders (Reasons for Tests).
The reason for the test should be documented either on the order, on the audiological evaluation report, or in
the patient’s medical record. (See subsection C. of this section concerning reasons for tests.)
2. Documenting skilled services. When the medical record is subject to medical review, it is necessary that
the record contains sufficient information so that the MAC may determine that the service qualifies for
payment. For example, documentation should indicate that the test was ordered, that the reason for the test
results in coverage, and that the test was furnished to the patient by a qualified individual.
Records that support the appropriate provision of an audiological diagnostic test shall be made available to
the MAC on request.
F. Audiological Treatment.
There is no provision in the law for Medicare to pay audiologists for therapeutic services. For example,
vestibular treatment, auditory rehabilitation treatment, auditory processing treatment, and canalith
repositioning, while they are generally within the scope of practice of audiologists, are not those hearing and
balance assessment services that are defined as audiology services in 1861(ll)(3) of the Social Security Act
and, therefore, shall not be billed by audiologists to Medicare. Services for the purpose of hearing aid
evaluation and fitting are not covered regardless of how they are billed. Services identified as “always”
therapy in Pub. 100-04, chapter 5, section 20 may not be billed by hospitals, physicians, NPPs, or
audiologists when provided by audiologists. (See also Pub. 100-04, chapter 12, section 30.3.)
Treatment related to hearing may be covered under the speech-language pathology benefit when the services
are provided by speech-language pathologists. Treatment related to balance (e.g., services described by
“always therapy” codes 97001-97004, 97110, 97112, 97116, and 97750) may be covered under the physical
therapy or occupational therapy benefit when the services are provided by therapists or their assistants,
where appropriate. Covered therapy services incident to a physician’s service must conform to policies in
sections 60, 220, and 230 of this chapter. Audiological treatment provided under the benefits for physical
therapy and speech-language pathology services may also be personally provided and billed by physicians
and NPPs when the services are within their scope of practice and consistent with State and local laws.
For example, aural rehabilitation and signed communication training may be payable according to the
benefit for speech-language pathology services or as speech-language pathology services incident to a
physician’s or NPP’s service. Treatment for balance disorders may be payable according to the benefit for
physical therapy services or as a physical therapy service incident to the services of a physician or NPP. See
the policies in this chapter, sections 220 and 230, for details.
G. Assignment.
Nonhospital entities billing for the audiologist’s services may accept assignment under the usual procedure
or, if not accepting assignment, may charge the patient and submit a nonassigned claim on their behalf.
H. Opt Out and Mandatory Claims Submissions.
The opt out law does not define “physician” or “practitioner” to include audiologists; therefore, they may
not opt out of Medicare and provide services under private contracts. See section 40.4 of this chapter for
details.
When a physician or supplier furnishes a service that is covered by Medicare, then it is subject to the
mandatory claim submission provisions of section 1848(g)(4) of the Social Security Act. Therefore, if an
audiologist charges or attempts to charge a beneficiary any remuneration for a service that is covered by
Medicare, then the audiologist must submit a claim to Medicare.
I. Non-Audiology Services Furnished by Audiologists.
Audiologists may be qualified to furnish all or part of some diagnostic tests or treatments that are not
defined as audiology services under the MPFS, such as non-auditory evoked potentials or cerumen removal.
Audiologists may not bill Medicare for services that are not audiology services according to Medicare’s
definition (see list at: www.cms.gov/therapyservices). However, the labor for the Technical Component
(TC) of certain other diagnostic tests or treatment services may qualify to be billed when furnished by
audiologists under physician supervision when all the appropriate policies are followed.
When furnishing services that are not on the Medicare list of audiology services, the audiologist may or may
not be working within the scope of practice of an audiologist according to State law. The audiologist
furnishing the service must have the qualifications that are ordinarily required of any person providing that
service. Consult the following policies for details:
• Policies for physical therapy, occupational therapy, and speech-language pathology services are in
sections 220 and 230 of this chapter and in Pub. 100-04, chapter 5, sections 10 and 20.
• Policies for services furnished incident to physicians’ services in the physician’s office are in section
60 of this chapter.
• Policies for therapeutic services furnished incident to physicians’ services in the hospital outpatient
setting are in chapter 6, section 20.5, of this manual.
• Policies for diagnostic tests in the physician’s office are in section 80 of this chapter.
• Policies for diagnostic tests furnished in the hospital outpatient setting are in chapter 6, section 20.4,
of this manual.
Therapeutic or treatment services that are not audiology services and are not “always” therapy (according to
the policy in Pub.100-04, chapter 5, section 20) and are furnished by audiologists may be billed incident to
the services of a physician when all other appropriate requirements are met.
In addition, the TC or facility services for diagnostic tests that are not audiology services may be billed by
physicians or hospital outpatient departments when provided by qualified personnel (who may be
audiologists), and physicians and hospital outpatient departments may bill for these diagnostic tests when
provided by those qualified personnel under the specified level of physician supervision for the diagnostic
test.
80.3.1 - Definition of Qualified Audiologist
(Rev. 84; Issued: 02-29-08; Effective: 04-01-08; Implementation: 04-07-08)
Audiological tests require the skills of an audiologist and shall be furnished by qualified audiologists, or, in
States where it is allowed by State and local laws, by a physician or non-physician practitioner. Medicare is
not authorized to pay for these services when performed by audiological aides, assistants, technicians, or
others who do not meet the qualifications below. In cases where it is not clear, the MAC shall determine
whether a service is an audiological service that requires the skills of an audiologist and whether the
qualifications for an audiologist have been met.
Section 1861(ll)(3) of the Act, provides that a qualified audiologist is an individual with a master’s or
doctoral degree in audiology. Therefore, a Doctor of Audiology (AuD) 4
th
year student with a provisional
license from a State does not qualify unless he or she also holds a master’s or doctoral degree in audiology.
In addition, a qualified audiologist is an individual who:
• Is licensed as an audiologist by the State in which the individual furnishes such services, or
• In the case of an individual who furnishes services in a State which does not license audiologists has:
o Successfully completed 350 clock hours of supervised clinical practicum (or is in the process
of accumulating such supervised clinical experience), and
ο Performed not less than 9 months of supervised full-time audiology services after obtaining a
master’s or doctoral degree in audiology or a related field, and
ο Successfully completed a national examination in audiology approved by the Secretary.
If it is necessary to determine whether a particular audiologist is qualified under the above definition, the
A/B MAC (B) should check references. A/B MACs (B) in States that have statutory licensure or
certification should secure from the appropriate State agency a current listing of audiologists holding the
required credentials. Additional references for determining an audiologist’s professional qualifications are
the national directory published annually by the American Speech-Language-Hearing Association and
records and directories, which may be available from the State Licensing Authority.
80.4 - Coverage of Portable X-Ray Services Not Under the Direct Supervision of a
Physician
(Rev. 1, 10-01-03)
B3-2070.4
80.4.1 - Diagnostic X-Ray Tests
(Rev. 1, 10-01-03)
B3-2070.4.A
Diagnostic x-ray services furnished by a portable x-ray supplier are covered under Part B when furnished in
a place or residence used as the patient’s home and in nonparticipating institutions. These services must be
performed under the general supervision of a physician, the supplier must meet FDA certification
requirements, and certain conditions relating to health and safety (as prescribed by the Secretary) must be
met.
Diagnostic portable x-ray services are also covered under Part B when provided in participating SNFs and
hospitals, under circumstances in which they cannot be covered under hospital insurance, i.e., the services
are not furnished by the participating institution either directly or under arrangements that provide for the
institution to bill for the services. (See §250 for Part B services furnished to inpatients of participating and
nonparticipating institutions.)
80.4.2 - Applicability of Health and Safety Standards
(Rev. 1, 10-01-03)
B3-2070.4.B
The health and safety standards apply to all suppliers of portable x-ray services, except physicians who
provide immediate personal supervision during the administration of diagnostic x-ray services. Payment is
made only for services of approved suppliers who have been found to meet the standards. Notice of the
coverage dates for services of approved suppliers are given to A/B MACs (B) by the RO.
When the services of a supplier of portable x-ray services no longer meet the conditions of coverage,
physicians having an interest in the supplier’s certification status must be notified. The notification action
regarding suppliers of portable x-ray equipment is the same as required for decertification of independent
laboratories, and the procedures explained in §80.1.3 are followed.
80.4.3 - Scope of Portable X-Ray Benefit
(Rev. 71, Issued: 05-25-07, Effective: N/A; Implementation: July 2, 2007)
In order to avoid payment for services, which are inadequate or hazardous to the patient, the scope of the
covered portable x-ray benefit is defined as:
• Skeletal films involving the extremities, pelvis, vertebral column, or skull;
• Chest films which do not involve the use of contrast media (except routine screening procedures and
tests in connection with routine physical examinations);
• Abdominal films which do not involve the use of contrast media; and
• Diagnostic mammograms if the approved portable x-ray supplier, as defined in 42 CFR part 486,
subpart C, meets the certification requirements of section 354 of the Public Health Services Act, as
implemented by 21 CFR part 900, subpart B.
80.4.4 - Exclusions From Coverage as Portable X-Ray Services
(Rev. 1, 10-01-03)
B3-2070.4.D
Procedures and examinations which are not covered under the portable x-ray provision include the
following:
• Procedures involving fluoroscopy;
• Procedures involving the use of contrast media;
• Procedures requiring the administration of a substance to the patient or injection of a substance into
the patient and/or special manipulation of the patient;
• Procedures which require special medical skill or knowledge possessed by a doctor of medicine or
doctor of osteopathy or which require that medical judgment be exercised;
• Procedures requiring special technical competency and/or special equipment or materials;
• Routine screening procedures; and
• Procedures which are not of a diagnostic nature.
80.4.5 - Electrocardiograms
(Rev. 1, 10-01-03)
B3-2070.4.F
The taking of an electrocardiogram tracing by an approved supplier of portable x-ray services may be
covered as an “other diagnostic test.” The health and safety standards referred to in §80.4.2 are applicable to
such diagnostic EKG services, e.g., the technician must meet the personnel qualification requirements in the
conditions for coverage of portable x-ray services.
80.5 - Bone Mass Measurements (BMMs)
(Rev.70, Issued: 05-11-07, Effective: 01-01-07, Implementation: 07-02-07)
80.5.1 - Background
(Rev. 70, Issued: 05-11-07, Effective: 01-01-07, Implementation: 07-02-07)
On June 24, 1998, CMS published an Interim Final Rule with Comment Period (IFC) in the Federal
Register entitled "Medicare Coverage of and Payment for Bone Mass Measurements." This IFC
implemented section 4106 of the Balanced Budget Act of 1997 by establishing conditions for coverage and
frequency standards thereby providing uniform coverage under Medicare Part B. It was effective July1,
1998.
On December 1, 2006, CMS published the CY 2007 Physician Fee Schedule final rule. This rule
implemented several changes effective January 1, 2007, which are reflected below.
80.5.2 - Authority
(Rev. 70, Issued: 05-11-07, Effective: 01-01-07, Implementation: 07-02-07)
Definitions can be found in sections 1861(s)(15) and (rr)(1) of the Social Security Act (the Act). Conditions
for coverage and frequency standards can be found in 42 CFR 410.31. Denials as not reasonable and
necessary can be found at §1862(a)(1)(A) of the Act, 42 CFR 410.31(e), and 42 CFR 411.15(k).
80.5.3 - Definition
(Rev. 70, Issued: 05-11-07, Effective: 01-01-07, Implementation: 07-02-07)
BMM means a radiologic, radioisotopic, or other procedure that meets all of the following conditions:
• Is performed to identify bone mass, detect bone loss, or determine bone quality.
• Is performed with either a bone densitometer (other than single-photon or dual-photon
absorptiometry) or a bone sonometer system that has been cleared for marketing for BMM by the
Food and Drug Administration (FDA) under 21 CFR part 807, or approved for marketing under
21 CFR part 814.
• Includes a physician’s interpretation of the results.
80.5.4 - Conditions for Coverage
(Rev. 70, Issued: 05-11-07, Effective: 01-01-07, Implementation: 07-02-07)
Medicare covers BMM under the following conditions:
1. Is ordered by the physician or qualified nonphysician practitioner who is treating the beneficiary
following an evaluation of the need for a BMM and determination of the appropriate BMM to be used.
A physician or qualified nonphysician practitioner treating the beneficiary for purposes of this provision
is one who furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses
the results in the management of the patient. For the purposes of the BMM benefit, qualified
nonphysician practitioners include physician assistants, nurse practitioners, clinical nurse specialists, and
certified nurse midwives.
2. Is performed under the appropriate level of physician supervision as defined in 42 CFR 410.32(b).
3. Is reasonable and necessary for diagnosing and treating the condition of a beneficiary who meets the
conditions described in §80.5.6.
4. In the case of an individual being monitored to assess the response to or efficacy of an FDA-approved
osteoporosis drug therapy, is performed with a dual-energy x-ray absorptiometry system (axial skeleton).
5. In the case of any individual who meets the conditions of 80.5.6 and who has a confirmatory BMM, is
performed by a dual-energy x-ray absorptiometry system (axial skeleton) if the initial BMM was not
performed by a dual-energy x-ray absorptiometry system (axial skeleton). A confirmatory baseline
BMM is not covered if the initial BMM was performed by a dual-energy x-ray absorptiometry system
(axial skeleton).
80.5.5 - Frequency Standards
(Rev. 70, Issued: 05-11-07, Effective: 01-01-07, Implementation: 07-02-07)
Medicare pays for a screening BMM once every 2 years (at least 23 months have passed since the month the
last covered BMM was performed).
When medically necessary, Medicare may pay for more frequent BMMs. Examples include, but are not
limited to, the following medical circumstances:
• Monitoring beneficiaries on long-term glucocorticoid (steroid) therapy of more than 3 months.
• Confirming baseline BMMs to permit monitoring of beneficiaries in the future.
80.5.6 - Beneficiaries Who May be Covered
(Rev. 70, Issued: 05-11-07, Effective: 01-01-07, Implementation: 07-02-07)
To be covered, a beneficiary must meet at least one of the five conditions listed below:
1. A woman who has been determined by the physician or qualified nonphysician practitioner treating her
to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other
findings.
NOTE: Since not every woman who has been prescribed estrogen replacement therapy (ERT) may be
receiving an “adequate” dose of the therapy, the fact that a woman is receiving ERT should not preclude
her treating physician or other qualified treating nonphysician practitioner from ordering a bone mass
measurement for her. If a BMM is ordered for a woman following a careful evaluation of her medical
need, however, it is expected that the ordering treating physician (or other qualified treating
nonphysician practitioner) will document in her medical record why he or she believes that the woman is
estrogen-deficient and at clinical risk for osteoporosis.
2. An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis,
osteopenia, or vertebral fracture.
3. An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an
average of 5.0 mg of prednisone, or greater, per day, for more than 3 months.
4. An individual with primary hyperparathyroidism.
5. An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis
drug therapy.
80.5.7 - Noncovered BMMs
(Rev. 70, Issued: 05-11-07, Effective: 01-01-07, Implementation: 07-02-07)
The following BMMs are noncovered under Medicare because they are not considered reasonable and
necessary under section 1862(a)(1)(A) of the Act.
• Single photon absorptiometry (effective January 1, 2007).
• Dual photon absorptiometry (established in 1983).
80.5.8 - Claims Processing
(Rev. 70, Issued: 05-11-07, Effective: 01-01-07, Implementation: 07-02-07)
For instructions concerning payment methodology, HCPCS coding, and Medicare summary notice and
remittance advice messages, see chapter 13, section 140 of Pub. 100-04, Medicare Claims Processing
Manual.
80.5.9 - National Coverage Determinations (NCDs)
(Rev. 70, Issued: 05-11-07, Effective: 01-01-07, Implementation: 07-02-07)
In addition to these conditions for coverage, CMS may determine through the NCD process that additional
BMM systems are reasonable and necessary under section 1862(a)(1) of the Act for monitoring and
confirming baseline BMMs.
80.6 - Requirements for Ordering and Following Orders for Diagnostic Tests
(Rev. 80; Issued: 01-11-08; Effective: 01-01-03; Implementation: 11-19-07)
The following sections provide instructions about ordering diagnostic tests and for complying with such
orders for Medicare payment.
NOTE: Unless specified, these sections are not applicable in a hospital setting.
80.6.1 - Definitions
(Rev. 94, Issued: 08-29-08, Effective: 01-01-03, Implementation: 09-30-08)
Diagnostic Test
A “diagnostic test” includes all diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic
tests furnished to a beneficiary.
Treating Physician
A “treating physician” is a physician, as defined in §1861(r) of the Social Security Act (the Act), who
furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results of a
diagnostic test in the management of the beneficiary’s specific medical problem.
A radiologist performing a therapeutic interventional procedure is considered a treating physician. A
radiologist performing a diagnostic interventional or diagnostic procedure is not considered a treating
physician.
Treating Practitioner
A “treating practitioner” is a nurse practitioner, clinical nurse specialist, or physician assistant, as defined in
§1861(s)(2)(K) of the Act, who furnishes, pursuant to State law, a consultation or treats a beneficiary for a
specific medical problem, and who uses the result of a diagnostic test in the management of the beneficiary’s
specific medical problem.
Testing Facility
A “testing facility” is a Medicare provider or supplier that furnishes diagnostic tests. A testing facility may
include a physician or a group of physicians (e.g., radiologist, pathologist), a laboratory, or an independent
diagnostic testing facility (IDTF).
Order
An “order” is a communication from the treating physician/practitioner requesting that a diagnostic test be
performed for a beneficiary. The order may conditionally request an additional diagnostic test for a
particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by
the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be
delivered via the following forms of communication:
• A written document signed by the treating physician/practitioner, which is hand-delivered, mailed,
or faxed to the testing facility; NOTE: No signature is required on orders for clinical diagnostic
tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for
physician pathology services;
• A telephone call by the treating physician/practitioner or his/her office to the testing facility; and
• An electronic mail by the treating physician/practitioner or his/her office to the testing facility.
If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the
testing facility must document the telephone call in their respective copies of the beneficiary’s medical
records. While a physician order is not required to be signed, the physician must clearly document, in the
medical record, his or her intent that the test be performed.
80.6.2 - Interpreting Physician Determines a Different Diagnostic Test is Appropriate
(Rev. 80; Issued: 01-11-08; Effective: 01-01-03; Implementation: 11-19-07)
When an interpreting physician, e.g., radiologist, cardiologist, family practitioner, general internist,
neurologist, obstetrician, gynecologist, ophthalmologist, thoracic surgeon, vascular surgeon, at a testing
facility determines that an ordered diagnostic radiology test is clinically inappropriate or suboptimal, and
that a different diagnostic test should be performed (e.g., an MRI should be performed instead of a CT scan
because of the clinical indication), the interpreting physician/testing facility may not perform the unordered
test until a new order from the treating physician/practitioner has been received. Similarly, if the result of an
ordered diagnostic test is normal and the interpreting physician believes that another diagnostic test should
be performed (e.g., a renal sonogram was normal and based on the clinical indication, the interpreting
physician believes an MRI will reveal the diagnosis), an order from the treating physician must be received
prior to performing the unordered diagnostic test.
80.6.3 - Rules for Testing Facility to Furnish Additional Tests
(Rev. 80; Issued: 01-11-08; Effective: 01-01-03; Implementation: 11-19-07)
If the testing facility cannot reach the treating physician/practitioner to change the order or obtain a new
order and documents this in the medical record, then the testing facility may furnish the additional
diagnostic test if all of the following criteria apply:
• The testing center performs the diagnostic test ordered by the treating physician/practitioner;
• The interpreting physician at the testing facility determines and documents that, because of the
abnormal result of the diagnostic test performed, an additional diagnostic test is medically necessary;
• Delaying the performance of the additional diagnostic test would have an adverse effect on the care
of the beneficiary;
• The result of the test is communicated to and is used by the treating physician/practitioner in the
treatment of the beneficiary; and
• The interpreting physician at the testing facility documents in his/her report why additional testing
was done.
EXAMPLE:
The last cut of an abdominal CT scan with contrast shows a mass requiring a pelvic CT scan to further
delineate the mass; (b) a bone scan reveals a lesion on the femur requiring plain films to make a diagnosis.
80.6.4 - Rules for Testing Facility Interpreting Physician to Furnish Different or
Additional Tests
(Rev. 80; Issued: 01-11-08; Effective: 01-01-03; Implementation: 11-19-07)
The following applies to an interpreting physician of a testing facility who furnishes a diagnostic test to a
beneficiary who is not a hospital inpatient or outpatient. The interpreting physician must document
accordingly in his/her report to the treating physician/practitioner.
Test Design
Unless specified in the order, the interpreting physician may determine, without notifying the treating
physician/practitioner, the parameters of the diagnostic test (e.g., number of radiographic views obtained,
thickness of tomographic sections acquired, use or non-use of contrast media).
Clear Error
The interpreting physician may modify, without notifying the treating physician/practitioner, an order with
clear and obvious errors that would be apparent to a reasonable layperson, such as the patient receiving the
test (e.g., x-ray of wrong foot ordered).
Patient Condition
The interpreting physician may cancel, without notifying the treating physician/ practitioner, an order
because the beneficiary’s physical condition at the time of diagnostic testing will not permit performance of
the test (e.g., a barium enema cannot be performed because of residual stool in colon on scout KUB;
170.5PA/LAT of the chest cannot be performed because the patient is unable to stand). When an ordered
diagnostic test is cancelled, any medically necessary preliminary or scout testing performed is payable.
80.6.5 - Surgical/Cytopathology Exception
(Rev. 80; Issued: 01-11-08; Effective: 01-01-03; Implementation: 11-19-07)
This exception applies to an independent laboratory’s pathologist or a hospital pathologist who furnishes a
pathology service to a beneficiary who is not a hospital inpatient or outpatient, and where the treating
physician/practitioner does not specifically request additional tests the pathologist may need to perform.
When a surgical or cytopathology specimen is sent to the pathology laboratory, it typically comes in a
labeled container with a requisition form that reveals the patient demographics, the name of the
physician/practitioner, and a clinical impression and/or brief history. There is no specific order from the
surgeon or the treating physician/practitioner for a certain type of pathology service. While the pathologist
will generally perform some type of examination or interpretation on the cells or tissue, there may be
additional tests, such as special stains, that the pathologist may need to perform, even though they have not
been specifically requested by the treating physician/practitioner. The pathologist may perform such
additional tests under the following circumstances:
• These services are medically necessary so that a complete and accurate diagnosis can be reported
to the treating physician/practitioner;
• The results of the tests are communicated to and are used by the treating physician/practitioner in
the treatment of the beneficiary; and
• The pathologist documents in his/her report why additional testing was done.
EXAMPLE:
A lung biopsy is sent by the surgeon to the pathology department, and the pathologist finds a granuloma
which is suspicious for tuberculosis. The pathologist cultures the granuloma, sends it to bacteriology, and
requests smears for acid fast bacilli (tuberculosis). The pathologist is expected to determine the need for
these studies so that the surgical pathology examination and interpretation can be completed and the
definitive diagnosis reported to the treating physician for use in treating the beneficiary.
90 - X-Ray, Radium, and Radioactive Isotope Therapy
(Rev. 1, 10-01-03)
B3-2075
These services also include materials and services of technicians.
X-ray, radium, and radioactive isotope therapy furnished in a nonprovider facility require direct personal
supervision of a physician. The physician need not be in the same room, but must be in the area and
immediately available to provide assistance and direction throughout the time the procedure is being
performed. This level of physician involvement does not represent a physician’s service and cannot be
billed as a Part B service. The physician would have to furnish a reasonable and necessary professional
service as defined in §§30 of this chapter, in order for the physician’s activity to be covered.
However, effective for radiation therapy services furnished on or after April 1, 1989, radiologists’ weekly
treatment management services are covered.
A separate charge for the services of a physicist is not recognized unless such services are covered under the
“incident to” provision (§60.1 of this chapter) or the services are included as part of a technical component
service billed by a freestanding radiation therapy center. The incident to provision may also be extended to
include all necessary and appropriate services supplied by a radiation physicist assisting a radiologist when
the physicist is in the physician’s employ and working under his or her direct supervision.
100 - Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of
Fractures and Dislocations
(Rev. 1, 10-01-03)
B3-2079, A3-3110.3, HO-228.3,
Surgical dressings are limited to primary and secondary dressings required for the treatment of a wound
caused by, or treated by, a surgical procedure that has been performed by a physician or other health care
professional to the extent permissible under State law. In addition, surgical dressings required after
debridement of a wound are also covered, irrespective of the type of debridement, as long as the
debridement was reasonable and necessary and was performed by a health care professional acting within
the scope of his/her legal authority when performing this function. Surgical dressings are covered for as
long as they are medically necessary.
Primary dressings are therapeutic or protective coverings applied directly to wounds or lesions either on the
skin or caused by an opening to the skin. Secondary dressing materials that serve a therapeutic or protective
function and that are needed to secure a primary dressing are also covered. Items such as adhesive tape, roll
gauze, bandages, and disposable compression material are examples of secondary dressings. Elastic
stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure
garments for the arms and hands are examples of items that are not ordinarily covered as surgical dressings.
Some items, such as transparent film, may be used as a primary or secondary dressing.
If a physician, certified nurse midwife, physician assistant, nurse practitioner, or clinical nurse specialist
applies surgical dressings as part of a professional service that is billed to Medicare, the surgical dressings
are considered incident to the professional services of the health care practitioner. (See §§60.1, 180, 190,
200, and 210.) When surgical dressings are not covered incident to the services of a health care practitioner
and are obtained by the patient from a supplier (e.g., a drugstore, physician, or other health care practitioner
that qualifies as a supplier) on an order from a physician or other health care professional authorized under
State law or regulation to make such an order, the surgical dressings are covered separately under Part B.
Splints and casts, and other devices used for reductions of fractures and dislocations are covered under Part
B of Medicare. This includes dental splints.
110 - Durable Medical Equipment - General
(Rev. 1, 10-01-03)
B3-2100, A3-3113, HO-235, HHA-220
Expenses incurred by a beneficiary for the rental or purchases of durable medical equipment (DME) are
reimbursable if the following three requirements are met:
• The equipment meets the definition of DME (§110.1);
• The equipment is necessary and reasonable for the treatment of the patient’s illness or injury or to
improve the functioning of his or her malformed body member (§110.1); and
• The equipment is used in the patient’s home.
The decision whether to rent or purchase an item of equipment generally resides with the beneficiary, but the
decision on how to pay rests with CMS. For some DME, program payment policy calls for lump sum
payments and in others for periodic payment. Where covered DME is furnished to a beneficiary by a
supplier of services other than a provider of services, the DME MAC makes the reimbursement. If a
provider of services furnishes the equipment, the A/B MAC (A) or (HHH) makes the reimbursement. The
payment method is identified in the annual fee schedule update furnished by CMS.
The CMS issues quarterly updates to a fee schedule file that contains rates by HCPCS code and also
identifies the classification of the HCPCS code within the following categories.
Category Code Definition
IN Inexpensive and Other Routinely Purchased Items
FS Frequently Serviced Items
CR Capped Rental Items
OX Oxygen and Oxygen Equipment
OS Ostomy, Tracheostomy & Urological Items
SD Surgical Dressings
PO Prosthetics & Orthotics
SU Supplies
TE Transcutaneous Electrical Nerve Stimulators
The A/B MACs (A), (B), and (HHH), and DME MACs, where appropriate, use the CMS files to determine
payment rules. See the Medicare Claims Processing Manual, Chapter 20, “Durable Medical Equipment,
Surgical Dressings and Casts, Orthotics and Artificial Limbs, and Prosthetic Devices,” for a detailed
description of payment rules for each classification.
Payment may also be made for repairs, maintenance, and delivery of equipment and for expendable and
nonreusable items essential to the effective use of the equipment subject to the conditions in §110.2.
See the Medicare Benefit Policy Manual, Chapter 11, “End Stage Renal Disease,” for hemodialysis
equipment and supplies.
110.1 - Definition of Durable Medical Equipment
(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)
Durable medical equipment is equipment which:
• Can withstand repeated use;
• Is primarily and customarily used to serve a medical purpose;
• Generally is not useful to a person in the absence of an illness or injury; and
• Is appropriate for use in the home.
All requirements of the definition must be met before an item can be considered to be durable medical
equipment.
The following describes the underlying policies for determining whether an item meets the definition of
DME and may be covered.
A. Durability
An item is considered durable if it can withstand repeated use, i.e., the type of item that could normally be
rented. Medical supplies of an expendable nature, such as incontinent pads, lambs wool pads, catheters, ace
bandages, elastic stockings, surgical facemasks, irrigating kits, sheets, and bags are not considered “durable”
within the meaning of the definition. There are other items that, although durable in nature, may fall into
other coverage categories such as supplies, braces, prosthetic devices, artificial arms, legs, and eyes.
B. Medical Equipment
Medical equipment is equipment primarily and customarily used for medical purposes and is not generally
useful in the absence of illness or injury. In most instances, no development will be needed to determine
whether a specific item of equipment is medical in nature. However, some cases will require development
to determine whether the item constitutes medical equipment. This development would include the advice
of local medical organizations (hospitals, medical schools, medical societies) and specialists in the field of
physical medicine and rehabilitation. If the equipment is new on the market, it may be necessary, prior to
seeking professional advice, to obtain information from the supplier or manufacturer explaining the design,
purpose, effectiveness and method of using the equipment in the home as well as the results of any tests or
clinical studies that have been conducted.
1. Equipment Presumptively Medical
Items such as hospital beds, wheelchairs, hemodialysis equipment, iron lungs, respirators, intermittent
positive pressure breathing machines, medical regulators, oxygen tents, crutches, canes, trapeze bars,
walkers, inhalators, nebulizers, commodes, suction machines, and traction equipment presumptively
constitute medical equipment. (Although hemodialysis equipment is covered as a prosthetic device (§120),
it also meets the definition of DME, and reimbursement for the rental or purchase of such equipment for use
in the beneficiary’s home will be made only under the provisions for payment applicable to DME. See the
Medicare Benefit Policy Manual, Chapter 11, “End Stage Renal Disease,” §30.1, for coverage of home use
of hemodialysis.) NOTE: There is a wide variety in types of respirators and suction machines. The DME
MACs medical staff should determine whether the apparatus specified in the claim is appropriate for home
use.
2. Equipment Presumptively Nonmedical
Equipment which is primarily and customarily used for a nonmedical purpose may not be considered
“medical” equipment for which payment can be made under the medical insurance program. This is true
even though the item has some remote medically related use. For example, in the case of a cardiac patient,
an air conditioner might possibly be used to lower room temperature to reduce fluid loss in the patient and to
restore an environment conducive to maintenance of the proper fluid balance. Nevertheless, because the
primary and customary use of an air conditioner is a nonmedical one, the air conditioner cannot be deemed
to be medical equipment for which payment can be made.
Other devices and equipment used for environmental control or to enhance the environmental setting in
which the beneficiary is placed are not considered covered DME. These include, for example, room heaters,
humidifiers, dehumidifiers, and electric air cleaners. Equipment which basically serves comfort or
convenience functions or is primarily for the convenience of a person caring for the patient, such as
elevators, stairway elevators, and posture chairs, do not constitute medical equipment. Similarly, physical
fitness equipment (such as an exercycle), first-aid or precautionary-type equipment (such as preset portable
oxygen units), self-help devices (such as safety grab bars), and training equipment (such as Braille training
texts) are considered nonmedical in nature.
3. Special Exception Items
Specified items of equipment may be covered under certain conditions even though they do not meet the
definition of DME because they are not primarily and customarily used to serve a medical purpose and/or
are generally useful in the absence of illness or injury. These items would be covered when it is clearly
established that they serve a therapeutic purpose in an individual case and would include:
a. Gel pads and pressure and water mattresses (which generally serve a preventive purpose)
when prescribed for a patient who had bed sores or there is medical evidence indicating that
they are highly susceptible to such ulceration; and
b. Heat lamps for a medical rather than a soothing or cosmetic purpose, e.g., where the need for
heat therapy has been established.
In establishing medical necessity for the above items, the evidence must show that the item is included in the
physician’s course of treatment and a physician is supervising its use.
NOTE: The above items represent special exceptions and no extension of coverage to other items should be
inferred.
C. Necessary and Reasonable
Although an item may be classified as DME, it may not be covered in every instance. Coverage in a
particular case is subject to the requirement that the equipment be necessary and reasonable for treatment of
an illness or injury, or to improve the functioning of a malformed body member. These considerations will
bar payment for equipment which cannot reasonably be expected to perform a therapeutic function in an
individual case or will permit only partial therapeutic function in an individual case or will permit only
partial payment when the type of equipment furnished substantially exceeds that required for the treatment
of the illness or injury involved.
See the Medicare Claims Processing Manual, Chapter 1, “General Billing Requirements;” §60, regarding the
rules for providing advance beneficiary notices (ABNs) that advise beneficiaries, before items or services
actually are furnished, when Medicare is likely to deny payment for them. ABNs allow beneficiaries to
make an informed consumer decision about receiving items or services for which they may have to pay out-
of-pocket and to be more active participants in their own health care treatment decisions.
1. Necessity for the Equipment
Equipment is necessary when it can be expected to make a meaningful contribution to the treatment of the
patient’s illness or injury or to the improvement of his or her malformed body member. In most cases the
physician’s prescription for the equipment and other medical information available to the DME MAC will
be sufficient to establish that the equipment serves this purpose.
2. Reasonableness of the Equipment
Even though an item of DME may serve a useful medical purpose, the DME MAC or A/B MAC (A) must
also consider to what extent, if any, it would be reasonable for the Medicare program to pay for the item
prescribed. The following considerations should enter into the determination of reasonableness:
1. Would the expense of the item to the program be clearly disproportionate to the therapeutic
benefits which could ordinarily be derived from use of the equipment?
2. Is the item substantially more costly than a medically appropriate and realistically feasible
alternative pattern of care?
3. Does the item serve essentially the same purpose as equipment already available to the
beneficiary?
3. Payment Consistent With What is Necessary and Reasonable
Where a claim is filed for equipment containing features of an aesthetic nature or features of a medical
nature which are not required by the patient’s condition or where there exists a reasonably feasible and
medically appropriate alternative pattern of care which is less costly than the equipment furnished, the
amount payable is based on the rate for the equipment or alternative treatment which meets the patient’s
medical needs.
The acceptance of an assignment binds the supplier-assignee to accept the payment for the medically
required equipment or service as the full charge and the supplier-assignee cannot charge the beneficiary the
differential attributable to the equipment actually furnished.
4. Establishing the Period of Medical Necessity
Generally, the period of time an item of durable medical equipment will be considered to be medically
necessary is based on the physician’s estimate of the time that his or her patient will need the equipment.
See the Medicare Program Integrity Manual, Chapters 5 and 6, for medical review guidelines.
D. Definition of a Beneficiary’s Home
For purposes of rental and purchase of DME a beneficiary’s home may be his/her own dwelling, an
apartment, a relative’s home, a home for the aged, or some other type of institution (such as an assisted
living facility, or an intermediate care facility for individuals with intellectual disabilities (ICF/IID)).
However, an institution may not be considered a beneficiary’s home if it:
• Meets at least the basic requirement (see §1861(e)(1) of the Social Security Act (the Act)) in the
definition of a hospital, i.e., it is primarily engaged in providing by or under the supervision of
physicians, to inpatients, diagnostic and therapeutic services for medical diagnosis, treatment, and
care of injured, disabled, and sick persons, or rehabilitation services for the rehabilitation of injured,
disabled, or sick persons; or
• Meets at least the basic requirement (see §1819(a)(1) of the Act) in the definition of a skilled nursing
facility, i.e., it is primarily engaged in providing to inpatients skilled nursing care and related
services for patients who require medical or nursing care, or rehabilitation services for the
rehabilitation of injured, disabled, or sick persons.
Thus, if an individual is a patient in an institution or distinct part of an institution which provides the
services described in the bullets above, the individual is not entitled to have separate Part B payment made
for rental or purchase of DME. This is because such an institution may not be considered the individual’s
home (see §§1861(s)(6) and 1861(n) of the Act, the implementing regulations at 42 CFR 410.38(b), and
§2160B in the State Operations Manual (SOM, Pub. 100-07), Chapter 2).
As indicated in §2164 of the SOM, Chapter 2, all hospitals and SNFs that are Medicare-certified are
automatically considered to meet the basic requirement described in the applicable bullet above by reason of
the Medicare certification itself. Moreover, even an institution (or portion of an institution) that is not
certified for Medicare is precluded from being considered a patient’s home in this context if it meets either
of these basic requirements. See §2166 of the SOM, Chapter 2, for the administrative criteria used in
determining whether the basic requirement in the “SNF” definition is met by a nursing home that is not
Medicare-certified (including the non-Medicare portion of an institution that also contains a Medicare-
certified distinct part SNF).
If the patient is at home for part of a month and, for part of the same month is in an institution that cannot
qualify as his or her home, or is outside the U.S., monthly payments may be made for the entire month.
Similarly, if DME is returned to the provider before the end of a payment month because the beneficiary
died in that month or because the equipment became unnecessary in that month, payment may be made for
the entire month.
110.2 - Repairs, Maintenance, Replacement, and Delivery
(Rev. 203, Issued: 02-13-15, Effective: 07-01-15, Implementation: 07-06-15)
Under the circumstances specified below, payment may be made for repair, maintenance, and replacement
of medically required DME, including equipment which had been in use before the user enrolled in Part B of
the program. However, do not pay for repair, maintenance, or replacement of equipment in the frequent and
substantial servicing or oxygen equipment payment categories. In addition, payments for repair and
maintenance may not include payment for parts and labor covered under a manufacturer’s or supplier’s
warranty.
A. Repairs
To repair means to fix or mend and to put the equipment back in good condition after damage or wear.
Repairs to equipment which a beneficiary owns are covered when necessary to make the equipment
serviceable. However, do not pay for repair of previously denied equipment or equipment in the frequent
and substantial servicing or oxygen equipment payment categories. If the expense for repairs exceeds the
estimated expense of purchasing or renting another item of equipment for the remaining period of medical
need, no payment can be made for the amount of the excess. (See subsection C where claims for repairs
suggest malicious damage or culpable neglect.)
Since renters of equipment recover from the rental charge the expenses they incur in maintaining in working
order the equipment they rent out, separately itemized charges for repair of rented equipment are not
covered. This includes items in the frequent and substantial servicing, oxygen equipment, capped rental,
and inexpensive or routinely purchased payment categories which are being rented.
A new Certificate of Medical Necessity (CMN) and/or physician’s order is not needed for repairs.
For replacement items, see Subsection C below.
B. Maintenance
Routine periodic servicing, such as testing, cleaning, regulating, and checking of the beneficiary’s
equipment, is not covered. The owner is expected to perform such routine maintenance rather than a retailer
or some other person who charges the beneficiary. Normally, purchasers of DME are given operating
manuals which describe the type of servicing an owner may perform to properly maintain the equipment. It
is reasonable to expect that beneficiaries will perform this maintenance. Thus, hiring a third party to do such
work is for the convenience of the beneficiary and is not covered. However, more extensive maintenance
which, based on the manufacturers’ recommendations, is to be performed by authorized technicians, is
covered as repairs for medically necessary equipment which a beneficiary owns. This might include, for
example, breaking down sealed components and performing tests which require specialized testing
equipment not available to the beneficiary. Do not pay for maintenance of purchased items that require
frequent and substantial servicing or oxygen equipment.
Since renters of equipment recover from the rental charge the expenses they incur in maintaining in working
order the equipment they rent out, separately itemized charges for maintenance of rented equipment are
generally not covered. Payment may not be made for maintenance of rented equipment other than the
maintenance and servicing fee established for capped rental items. For capped rental items which have
reached the 13-month rental cap, contractors pay claims for maintenance and servicing fees after 6 months
have passed from the end of the final paid rental month or from the end of the period the item is no longer
covered under the supplier’s or manufacturer’s warranty, whichever is later. See the Medicare Claims
Processing Manual, Chapter 20, “Durable Medical Equipment, Prosthetics and Orthotics, and Supplies
(DMEPOS),” for additional instruction and an example.
A new CMN and/or physician’s order is not needed for covered maintenance.
In cases where one or more monthly rental payments have been made in accordance with 42 CFR 414.229
for a capped rental DME item, medical necessity for the equipment has been established. In cases where
one or more rental payments have been made for an item classified as capped rental DME, and the supplier
transfers title to the equipment prior to the end of a 13 month period of continuous use per 42 CFR 414.230,
Medicare payment can be made for reasonable and necessary maintenance and servicing of the beneficiary-
owned DME. Under the regulations at 42 CFR 414.210(e)(1), reasonable and necessary charges for
maintenance and servicing are those made for parts and labor not otherwise covered under a manufacturer’s
or supplier’s warranty. Charges for routine maintenance and servicing would not be covered. Charges for
maintenance and servicing that exceed the purchase price of the equipment (i.e., the capped rental monthly
fee multiplied by 10) would not be reasonable and necessary and should be denied.
C. Replacement
Replacement refers to the provision of an identical or nearly identical item. Situations involving the
provision of a different item because of a change in medical condition are not addressed in this section.
Equipment which the beneficiary owns or is a capped rental item may be replaced in cases of loss or
irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire,
flood). A physician’s order and/or new Certificate of Medical Necessity (CMN), when required, is needed
to reaffirm the medical necessity of the item.
Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event
cannot be identified. Replacement of equipment due to irreparable wear takes into consideration the
reasonable useful lifetime of the equipment. If the item of equipment has been in continuous use by the
patient on either a rental or purchase basis for the equipment’s useful lifetime, the beneficiary may elect to
obtain a new piece of equipment. Replacement may be reimbursed when a new physician order and/or new
CMN, when required, is needed to reaffirm the medical necessity of the item.
The reasonable useful lifetime of durable medical equipment is determined through program instructions. In
the absence of program instructions, A/B MACS (B) may determine the reasonable useful lifetime of
equipment, but in no case can it be less than 5 years. Computation of the useful lifetime is based on when
the equipment is delivered to the beneficiary, not the age of the equipment. Replacement due to wear is not
covered during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime,
Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically
necessary equipment owned by the beneficiary. (See subsection A.)
Charges for the replacement of oxygen equipment, items that require frequent and substantial servicing or
inexpensive or routinely purchased items which are being rented are not covered.
Cases suggesting malicious damage, culpable neglect, or wrongful disposition of equipment should be
investigated and denied where the DME MACs determines that it is unreasonable to make program payment
under the circumstances. DME MACs refer such cases to the program integrity specialist in the RO.
D. Delivery
Payment for delivery of DME whether rented or purchased is generally included in the fee schedule
allowance for the item. See Pub. 100-04, Medicare Claims Processing Manual, Chapter 20, “Durable
Medical Equipment, Prosthetics and Orthotics, and Supplies (DMEPOS),” for the rules that apply to making
reimbursement for exceptional cases.
110.3 - Coverage of Supplies and Accessories
(Rev. 1, 10-01-03)
B3-2100.5, A3-3113.4, HO-235.4, HHA-220.5
Payment may be made for supplies, e.g., oxygen, that are necessary for the effective use of durable medical
equipment. Such supplies include those drugs and biologicals which must be put directly into the equipment
in order to achieve the therapeutic benefit of the durable medical equipment or to assure the proper
functioning of the equipment, e.g., tumor chemotherapy agents used with an infusion pump or heparin used
with a home dialysis system. However, the coverage of such drugs or biologicals does not preclude the need
for a determination that the drug or biological itself is reasonable and necessary for treatment of the illness
or injury or to improve the functioning of a malformed body member.
In the case of prescription drugs, other than oxygen, used in conjunction with durable medical equipment,
prosthetic, orthotics, and supplies (DMEPOS) or prosthetic devices, the entity that dispenses the drug must
furnish it directly to the patient for whom a prescription is written. The entity that dispenses the drugs must
have a Medicare supplier number, must possess a current license to dispense prescription drugs in the State
in which the drug is dispensed, and must bill and receive payment in its own name. A supplier that is not the
entity that dispenses the drugs cannot purchase the drugs used in conjunction with DME for resale to the
beneficiary. Reimbursement may be made for replacement of essential accessories such as hoses, tubes,
mouthpieces, etc., for necessary DME, only if the beneficiary owns or is purchasing the equipment.
110.4 - Miscellaneous Issues Included in the Coverage of Equipment
(Rev. 1, 10-01-03)
B3-2100.6, A3-3113.5, HO-235.5, HHA-220.6
Payment can be made for the purchase of DME even though rental payments may have been made for prior
months. This could occur where, because of a change in his/her condition, the beneficiary feels that it would
be to his/her advantage to purchase the equipment rather than to continue to rent it.
A beneficiary may sell or otherwise dispose of equipment for which they have no further use, for example,
because of recovery from the illness or injury that gave rise to the need for the equipment. (There is no
authority for the program to repossess the equipment.) If after such disposal there is again medical need for
similar equipment, payment can be made for the rental or purchase of that equipment.
However, where an arrangement is motivated solely by a desire to create artificial expenses to be met by the
program and to realize a profit thereby, such expenses would not be covered under the program. The
resolution of questions involving the disposition and subsequent acquisition of durable medical equipment
must be made on a case-by-case basis.
Cases where it appears that there has been an attempt to create an artificial expense and realize a profit
thereby should be developed and when appropriate denied. After adjudication the DME MAC would refer
such cases to the program integrity specialist in the RO.
When payments stop because the beneficiary’s condition has changed and the equipment is no longer
medically necessary, the beneficiary is responsible for the remaining noncovered charges. Similarly, when
payments stop because the beneficiary dies, the beneficiary’s estate is responsible for the remaining
noncovered charges.
Contractors do not get involved in issues relating to ownership or title of property.
110.5 - Incurred Expense Dates for Durable Medical Equipment
(Rev. 1, 10-01-03)
A3-3113.7.B, HO-235.7.B, B3-3011
The date of service on the claim must be the date that the beneficiary or authorized representative received
the DMEPOS item. If the date of delivery is not specified on the bill, the contractor should assume, in the
absence of evidence to the contrary, that the date of purchase was the date of delivery.
For mail order DMEPOS items, the date of service on the claim must be the shipping date.
The date of service on the claim must be the date that the DMEPOS item(s) was received by the nursing
facility if the supplier delivered it or the shipping date if the supplier utilized a delivery/shipping service.
An exception to the preceding statements concerning the date of service on the claim occurs when items are
provided in anticipation of discharge from a hospital or nursing facility. If a DMEPOS item is delivered to a
patient in a hospital up to two days prior to discharge to home and it is for the benefit of the patient for
purposes of fitting or training of the patient on its use, the supplier should bill the date of service on the
claim as the date of discharge to home and should use POS=12.
See the Medicare Program Integrity Manual, Chapter 5, “Items and Services Having Special DME Review
Considerations,” for additional information pertaining to the date of service on the claim. Also see the
Medicare Claims Processing Manual, Chapter 20, “Durable Medical Equipment, Surgical dressings and
Casts, Orthotics and Artificial Limbs, and Prosthetic Devices,” for additional DME billing and claims
processing information.
110.6 - Determining Months for Which Periodic Payments May Be Made for
Equipment Used in an Institution
(Rev. 1, 10-01-03)
A3-3113.7.D, HO-235.7.C
If a patient uses equipment subject to the monthly payment rule in an institution, which does not qualify as
his or her home, the used months during which the beneficiary was institutionalized are not covered.
110.7 - No Payment for Purchased Equipment Delivered Outside the United States or
Before Beneficiary’s Coverage Began
(Rev. 1, 10-01-03)
A3-3113.7.C
In the case of equipment subject to the lump sum payment rules, the beneficiary must have been in the
United States and must have had Medicare coverage at the time the item was delivered. Therefore, where an
item of durable medical equipment paid for as a lump sum was delivered to an individual outside the United
States or before his or her coverage period began, the entire expense of the item would be excluded from
coverage. Payment cannot be made in such cases even though the individual later uses the item inside the
United States or after his or her coverage begins.
If the individual is outside the U.S. for more than 30 days and then returns to the U.S., the DME MAC
determines medical necessity as in an initial case before resuming payments.
110.8 – DMEPOS Benefit Category Determinations
(Rev. 12684; Issued:06-13-24, Effective: 04-01-24, Implementation: 07-15-24)
A. General
Whether or not an item or service falls under a Medicare benefit category, such as the
Medicare Part B benefit category for DME, is a necessary step in determining whether an item
may be covered under the Medicare program and, if applicable, what statutory and regulatory
payment rules apply to the items and services. If the item is excluded from coverage by the Act
or does not fall within the scope of a defined benefit category, the item cannot be covered
under Medicare Part B.
Medicare Durable Medical Equipment, Prosthetic Devices, Prosthetics, Orthotics and Supplies
(DMEPOS) benefit category determinations established on or after September 26, 2022,
through rulemaking or in accordance with the procedures at 42 CFR §414.114, §414.240 and
§414.1670, are listed below. These procedures consider public consultation furnished at public
meetings and in writing in accordance with requirements for new DME items by section 531(b)
of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000
(BIPA) (Pub L. 106-554). These procedures are often performed in coordination with
Healthcare Common Procedure Coding System (HCPCS) code decisions. This section is a
quick reference tool for the benefit categories of items and services evaluated using the
procedures described above. The section is organized alphabetically by the categories of items
and services and then by the benefit category determination with effective date.
The benefit category and payment rules for items and services that are assigned to an existing
(HCPCS) code(s) are determined by the benefit category and payment rules for that HCPCS
code(s). Additional benefit category determinations established before 2022 for DME items
are available in CMS Pub. 100-03 Chapter 1, Part 4, Section 280.1 Durable Medical
Equipment Reference List. More information on HCPCS code decisions and benefit category
determinations for items and services reviewed using the process described above is available
at https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system
DMEPOS Benefit Category Determinations
Item
Benefit Category Determination
Effective
Date
Addition, Endoskeletal Knee-
Shin System, 4 Bar Linkage or
Multiaxial, Fluid Swing and
Stance Phase Control
Prosthetic (Artificial Leg)-Microprocessor-
controlled knee added to a prosthetic leg that utilizes
a 4-bar geometry with hydraulic control of both
stance and swing phases of gait.
10-1-22
Addition, Endoskeletal Knee-
Shin System, Polycentric,
Pneumatic Swing, and Stance
Phase Control
Prosthetic (Artificial Leg)-Prosthetic endoskeletal
knee-shin system that provides pneumatic swing and
stance control.
4-1-24
Addition to Lower Extremity
Prosthesis, Endoskeletal Knee
Disarticulation, Above Knee,
Hip Disarticulation, Positional
Rotation Unit
Prosthetic (Artificial Leg)-Added to a prosthetic leg
to provide 360-degree rotation of the prosthetic limb
to accommodate specific environmental situations.
10-1-22
Addition to Lower Extremity
Prosthesis, Osseointegrated
External Prosthetic Connector
Prosthetic (Artificial Leg)-Connection device
between implantable components and external
prosthetic components such as prosthetic knee and
foot.
10-1-23
Addition to Lower Extremity,
User Adjustable, Mechanical,
Residual Limb Volume
Management System
Prosthetic (Artificial Leg)-Added to a lower
extremity prosthetic socket.
4-1-24
Adhesive clip applied to the
skin to secure external
electrical nerve stimulator
controller
Prosthetic Supply-Supply used with Prosthetic
Device
4-1-24
Bilateral hip, knee, ankle, foot
device, powered, includes
pelvic component, single or
double upright(s), knee joints
any type, with or without ankle
joints any type, includes all
components and accessories,
motors, microprocessors,
sensors
Orthotic (Leg Brace)-Lower body exoskeleton
system worn to enable ambulation for user with
disorders such as paralysis.
1-1-24
Cranial Electrotherapy
Stimulation System
DME--These devices utilize a microcurrent to
deliver proprietary low-level electrical signals trans
cranially to treat insomnia, depression, anxiety, and
pain.
10-1-22
Complex Rehabilitative Power
Wheelchair Accessory, Power
Seat Elevation System, Any
Type
DME--Component of a complex rehabilitative power
wheelchair that raises and lowers a user while in a
seated position to varying amounts of vertical
height.
4-1-24
Disposable Collection and
Storage Bag for Breast Milk,
Any Size
No DMEPOS Benefit Category--There is no
DMEPOS benefit category for disposable supplies.
Also, electric breast pumps are not classified as
DME. Therefore, disposable supplies used with
these items would not fall under a DMEPOS benefit
category. For manual breast pumps and related
supplies, the Medicare Administrative Contractor
processing claims for these items would determine
whether or not the pump is DME on a claim-by-
claim basis
10-1-22
Distal Transcutaneous
Electrical Nerve Stimulator,
Stimulates Peripheral Nerves of
the Upper Arm
No DMEPOS Benefit Category--Minimum lifetime
requirement of at least three years not met
10-1-22
Electrical stimulator supplies
(external) for use with
implantable neurostimulator,
per month
Prosthetic Device--Accessories for neuromodulation
systems indicated for pain management in adults
who have severe intractable pain of peripheral nerve
origin.
4-1-23
Electronic Positional
Obstructive Sleep Apnea
Treatment Equipment, With
Sensor
DME--Classified as DME if FDA clearance
expressly states it is for the treatment of positional
obstructive sleep apnea and is not clinically
indicated or marketed for anti-snoring or other non-
medical uses and all other requirements for
classification as DME in accordance with §414.202
are met.
10-1-22
Enema Tube, With or Without
Adapter
No DMEPOS Benefit Category--These items cannot
withstand repeated use and are therefore not DME.
Rectal catheters or tubes are not prosthetic devices
because they do not replace all or part of an internal
body organ or all or part of the function of a
permanently inoperative or malfunctioning internal
body organ.
10-1-22
Enteral feeding supply kit;
elastomeric control fed, per
day, includes but not limited to
feeding/flushing syringe,
administration set tubing,
dressings, tape
Prosthetic Device--Portable, lightweight, non-
electronic, disposable enteral feeding system.
10-1-23
Expiratory Positive Airway
Pressure Intranasal Resistance
Valve
No DMEPOS Benefit Category--These are single-
patient, reusable expiratory positive airway pressure
(EPAP) devices for the treatment of obstructive
sleep apnea. These single-patient items cannot
withstand repeated use and therefore are not DME.
4-1-23
External Upper Limb Tremor
Stimulator of the Peripheral
Nerves of the Wrist
DME--Delivers electrical stimulation to the nerves
in the wrist to stimulate the peripheral nervous
system for the treatment of essential tremors.
10-1-22
Fertility cycle (contraception &
conception) tracking software
application, fda cleared, per
month, includes accessories
(e.g., thermometer)
No DMEPOS Benefit Category—Software
applications (apps) are not devices, equipment, or
supplies and do not fall under a DMEPOS benefit
category.
4-1-24
Foot Adductus Positioning
Device, Adjustable
Orthotic (Leg Brace)-Foot positioning devices that
stabilize the heel in the heel cage and the rest of the
foot in the device while applying corrective
pressures to the midfoot, thereby realigning the
malformed pediatric foot. This is considered to be an
alternative to serial casting. The devices treat
newborns with semiflexible and rigid metatarsus
adductus/varus, as well as flexible metatarsus
adductus/varus that does not respond to stretching.
10-1-22
Hip orthosis, bilateral hip joints
and thigh cuffs, adjustable
flexion, extension, abduction
control of hip joint,
postoperative hip abduction
type, prefabricated item that
has been trimmed, bent,
molded, assembled, or
otherwise customized to fit a
specific patient by an
individual with expertise
Orthotic (Leg Brace)-Prefabricated,
custom fitted, hip orthosis designed for bilateral
post-operative hip range of motion control.
10-1-23
Home Ventilator, dual-function
respiratory device, also
performs additional function of
cough stimulation, includes all
accessories, components and
supplies for all functions
DME-- Assists with ventilation and cough
stimulation and falls under the multi-function
ventilator definition in 42 CFR §414.222(f)(1).
4-1-24
Hydrophilic, with Blue-Violet
Filter Contact Lens
No DMEPOS Benefit Category --These lenses do
not qualify as prosthetic devices under any of the
categories for prosthetic lenses under section 120.B
of chapter 15 of the Medicare Benefit Policy
Manual.
10-1-23
Hydrophilic, Dual Focus
Contact Lens
No DMEPOS Benefit Category--Contact lens used
for the correction of myopic ametropia and for
slowing the progression of myopia in children.
These lenses do not qualify as prosthetic devices
under any of the categories for prosthetic lenses
under section 120.B of chapter 15 of the Medicare
Benefit Policy Manual.
10-1-22
Hydrophilic, Spherical Contact
Lens with Photochromic
Additive
Prosthetic Device--Refractive lenses are covered as
prosthetic lenses under the benefit category for
prosthetic devices when they are used to restore the
vision normally provided by the natural lens of the
eye of an individual lacking the organic lens because
of surgical removal or congenital absence. Covered
diagnoses are limited to pseudophakia (condition in
which the natural lens has been replaced with an
artificial intraocular lens (IOL), aphakia (condition
in which the natural lens has been removed but there
is no IOL, and congenital aphakia. Lenses provided
for other diagnoses will be denied as noncovered.
Coverage may be limited to one pair of eyeglasses or
contact lenses. Because coverage of refractive lenses
is based upon the prosthetic device benefit category,
there is no coverage for frames or lens add-on codes
unless there is a covered lens(es). Tinted lenses,
including photochromatic lenses, used as sunglasses,
which are prescribed in addition to regular prosthetic
lenses to a pseudophakic beneficiary, will be denied
as noncovered.
10-1-22
Indwelling intraurethral
drainage device with valve,
patient inserted
Prosthetic Device--Urethral insert with a valve for
bladder drainage. The intraurethral device replaces
the function of a permanently inoperative bladder.
4-1-23
Integrated lancing and blood
sample testing cartridges for
home blood glucose monitor,
per month
DME--Supply used with Durable Medical
Equipment.
4-1-24
Knee Ankle Foot Device, Any
Material, Single or Double
Upright, Swing and Stance
Phase Microprocessor Control
with Adjustability, Includes All
Components (e.g., Sensors,
Batteries, Charger), Any Type
Activation, with or without
Ankle Joint(s), Custom
Fabricated
Orthotic (Leg Brace)-Rigid device used for the
purpose of supporting a weak or deformed leg.
10-1-22
Low Frequency Ultrasonic
Diathermy Treatment Device
for Home Use
No DMEPOS Benefit Category--Minimum lifetime
requirement of at least three years not met. These
items are not the standard pulses wave types of
diathermy machines referenced in section 280.1 of
chapter 1, part 4 of the National Coverage
Determinations Manual. However, the equipment
must be able to be rented and used by multiple
patients for a minimum of three years in order to be
classified as DME.
10-1-22
Mechanical Allergen Particle
Barrier/Inhalation Filter,
Cream, Nasal, Topical
No DMEPOS Benefit Category--Minimum lifetime
requirement of at least three years not met.
10-1-22
Mechanical Vibration Device
for Massage Stimulation
No DMEPOS Benefit Category--Mechanical
vibration devices for massage stimulation are
personal comfort items excluded from Medicare
coverage by section 1862(a)(6) of the Social
Security Act.
4-1-24
Molecular diagnostic test
reader, nonprescription self-
administered and self-collected
use, fda approved, authorized
or cleared
No DMEPOS Benefit Category--In vitro diagnostic
medical device for analyzing specimens in the home
collected with the single-use cartridges.
4-1-23
Neuromodulation Stimulator
System, adjunct to
rehabilitation therapy regime
DME--Neuromodulation stimulator device designed
to assist with gait deficit.
4-1-24
Neuromodulation Stimulator
System, adjunct to
rehabilitation therapy regime,
mouthpiece
DME--Supply used with Durable Medical
Equipment
4-1-24
Neuromuscular electrical
stimulator (nmes), disposable,
replacement only
No DMEPOS Benefit Category— These single-
patient items cannot withstand repeated use and
therefore are not DME.
4-1-23
Non-Invasive Vagus Nerve
Stimulator
DME--Devices to stimulate the cervical branch of
the vagus nerve when applied to the side of the neck
through two stainless steel stimulation surfaces.
10-1-22
Non-Pneumatic Compression
Controller
DME--These devices use non-pneumatic
compression to treat and manage lymphedema.
10-1-22
Oral Device/Appliance for
Neuromuscular Electrical
Stimulation of the Tongue
Muscle for the Reduction of
Snoring and Obstructive Sleep
Apnea, Controlled by Phone
Application
No DMEPOS Benefit Category--The component
that performs the medically necessary function of
the device is a smartphone which is useful to an
individual in the absence of an illness or injury.
10-1-22
Oral Device/Appliance for
Neuromuscular Electrical
Stimulation of the Tongue
Muscle for the Reduction of
Snoring and Obstructive Sleep
Apnea, Controlled by
Hardware Remote
DME--The component that performs the medically
necessary function of the device is a durable control
unit and a hardware remote.
10-1-23
Oral mucoadhesive, any type
(liquid, gel, paste, etc)
No DMEPOS Benefit Category--Oral mucoadhesive
is not a surgical dressing covered under Section
1861(s)(5) of the Act and does not fall under any
other DMEPOS benefit category.
10-1-23
Pessary, disposable, any type
Prosthetic Device--Pessary for temporary,
nonsurgical management of pelvic organ prolapse in
females.
4-1-24
Powered Pressure Reducing
Underlay/pad, Alternating,
With Pump
DME--Decubitus care equipment which uses
alternating turning pressure pad placed under the
mattress rather than on top of the mattress.
10-1-22
Prescription Digital Therapy
No DMEPOS Benefit Category--Digital therapies or
computer software are housed on non-medical
devices like smartphones or computers and the
equipment and software as a whole are not DME.
10-1-22
Programable, transient, orally
ingested capsule, for use with
external programmer, per
month
No DMEPOS Benefit Category--The component
that performs the medically necessary function of
the device is a non-durable capsule.
10-1-23
Powered upper extremity range
of motion assist device, elbow,
wrist, hand with single or
double upright(s), includes
microprocessor, sensors, all
components and accessories,
custom fabricated
Orthotic (Arm Brace)-Motorized, microprocessor
controlled, elbow-wrist-hand device used for patients
experiencing complications of stroke or other
neurological/neuromuscular injury and illness.
1-1-24
Powered upper extremity range
of motion assist device, elbow,
wrist, hand, finger, single or
double upright(s), includes
microprocessor, sensors, all
components and accessories,
custom fabricated
Orthotic (Arm Brace)-Motorized, microprocessor
controlled, elbow-wrist-hand-finger device used for
patients experiencing complications of stroke or other
neurological/neuromuscular injury and illness.
1-1-24
Rehab system with interactive
Interface Providing Active
Assistance in Rehabilitation
Therapy, includes all
components and accessories,
motors, microprocessors,
sensors
DME--Device provides rehabilitation to hand or
foot.
4-1-24
Speech Volume Modulation
System
DME--These devices are worn behind the ear and
play background noise (multi-talker babble) in the
patient’s ear only when the patient speaks. The noise
elicits the Lombard Effect, automatically increasing
the patient’s vocal intensity, slowing their speech
rate, and/or increasing the clarity of their speech.
10-1-22
Suction Pump, Home Model,
Portable or Stationary, Electric,
for Use with External Urine
Management System
DME--Home suction pumps have been classified as
DME under the HCPCS since 1984 or earlier. This
type of home suction pump is used for urine
collection or drainage.
10-1-22
Thoracic, pectus carinatum
orthosis, sternal compression,
rigid circumferential frame
with anterior and posterior
rigid pads, custom fabricated
Orthotic (Brace)
4-1-24
Transcutaneous Electrical
Nerve Stimulator for Electrical
Stimulation of the Trigeminal
Nerve
DME--Devices used during sleep for the treatment
for pediatric attention deficit hyperactivity disorder
(ADHD).
10-1-22
Transcutaneous tibial nerve
simulator
DME--Device performs transcutaneous tibial nerve
stimulation.
4-1-24
Upper extremity medical
tubing/lines enclosure or
covering device, restricts elbow
range of motion
No DMEPOS Benefit Category--The device is
safety equipment to prevent patient entanglement
when stationary or mobile with vital tubes, lines and
catheters. There is not a benefit category under
Medicare Part B for safety equipment used in the
home.
4-1-23
Upper extremity rehabilitation
system providing active
assistance to facilitate muscle
re-education, include
microprocessor, all
components and accessories
DME--Device assists to facilitate muscle re-
education.
4-1-24
Virtual reality cognitive
behavioral therapy device (cbt),
including pre-programmed
therapy software
DME--The device delivers a clinically based
multimodal pain self-management program
incorporating evidence-based principles of
Cognitive Behavioral Therapy (CBT).
4-1-23
Walker component for extra
power to ambulate harder
terrain outside the home,
folding, adjustable or fixed
height
No DMEPOS benefit category--Item assists with
extra power to ambulate harder terrain outside the
home (i.e. uphill, grassy field, longer distances).
Item does not serve a medical purpose for use in the
home.
4-1-24
Wheelchair Accessory:
Dynamic Positioning Hardware
for Back
DME--These items are hardware added to the
wheelchair to absorb the force of a patient’s
uncontrollable backward jerking motions is
classified as DME if necessary for the effective use
of a wheelchair classified as DME.
10-1-22
Whirlpool Tub, Walk-In,
Portable
No DMEPOS Benefit Category--A portable
hydrotherapy unit or whirlpool is useful to
individuals in the absence of an illness or injury for
relaxation and soothing sore muscles. Per section
280.1 of chapter 1, part 4 of the Medicare National
Coverage Determinations Manual, portable
whirlpool pumps are not DME because they are not
primarily medical in nature and are personal comfort
items excluded from Medicare coverage
(§1862(a)(6) of the Act).
10-1-22
B. DMEPOS Benefit category Determinations for Miscellaneous Items and Services
The instructions in section A. apply to all claims for items and services billed using HCPCS codes for
specific items and services that have national BCDs. For claims for items and services billed using HCPCS
codes for miscellaneous DMEPOS items and services (e.g., A9999, B9999, E1399, K0108, L3999), the
contractors must determine if the item or service falls within one of the benefit categories for DMEPOS and
whether or not the item or service is excluded from coverage in accordance with the rules of section 1862 of
the Social Security Act and other Medicare laws, regulations, and program instructions. These
determinations are made on an individual, claim-by-claim basis.
120 - Prosthetic Devices
(Rev. 1, 10-01-03)
B3-2130, A3-3110.4, HO-228.4, A3-3111, HO-229
A. General
Prosthetic devices (other than dental) which replace all or part of an internal body organ
(including contiguous tissue), or replace all or part of the function of a permanently
inoperative or malfunctioning internal body organ are covered when furnished on a
physician’s order. This does not require a determination that there is no possibility that
the patient’s condition may improve sometime in the future. If the medical record,
including the judgment of the attending physician, indicates the condition is of long and
indefinite duration, the test of permanence is considered met. (Such a device may also be
covered under §60.l as a supply when furnished incident to a physician’s service.)
Examples of prosthetic devices include artificial limbs, parenteral and enteral (PEN)
nutrition, cardiac pacemakers, prosthetic lenses (see subsection B), breast prostheses
(including a surgical brassiere) for postmastectomy patients, maxillofacial devices, and
devices which replace all or part of the ear or nose. A urinary collection and retention
system with or without a tube is a prosthetic device replacing bladder function in case of
permanent urinary incontinence. The foley catheter is also considered a prosthetic device
when ordered for a patient with permanent urinary incontinence. However, chucks,
diapers, rubber sheets, etc., are supplies that are not covered under this provision.
Although hemodialysis equipment is a prosthetic device, payment for the rental or
purchase of such equipment in the home is made only for use under the provisions for
payment applicable to durable medical equipment.
An exception is that if payment cannot be made on an inpatient’s behalf under Part A,
hemodialysis equipment, supplies, and services required by such patient could be covered
under Part B as a prosthetic device, which replaces the function of a kidney. See the
Medicare Benefit Policy Manual, Chapter 11, “End Stage Renal Disease,” for payment
for hemodialysis equipment used in the home. See the Medicare Benefit Policy Manual,
Chapter 1, “Inpatient Hospital Services,” §10, for additional instructions on
hospitalization for renal dialysis.
NOTE: Medicare does not cover a prosthetic device dispensed to a patient prior to the
time at which the patient undergoes the procedure that makes necessary the use of the
device. For example, the A/B MAC (B) does not make a separate Part B payment for an
intraocular lens (IOL) or pacemaker that a physician, during an office visit prior to the
actual surgery, dispenses to the patient for his or her use. Dispensing a prosthetic device
in this manner raises health and safety issues. Moreover, the need for the device cannot
be clearly established until the procedure that makes its use possible is successfully
performed. Therefore, dispensing a prosthetic device in this manner is not considered
reasonable and necessary for the treatment of the patient’s condition.
Colostomy (and other ostomy) bags and necessary accouterments required for attachment
are covered as prosthetic devices. This coverage also includes irrigation and flushing
equipment and other items and supplies directly related to ostomy care, whether the
attachment of a bag is required.
Accessories and/or supplies which are used directly with an enteral or parenteral device
to achieve the therapeutic benefit of the prosthesis or to assure the proper functioning of
the device may also be covered under the prosthetic device benefit subject to the
additional guidelines in the Medicare National Coverage Determinations Manual.
Covered items include catheters, filters, extension tubing, infusion bottles, pumps (either
food or infusion), intravenous (I.V.) pole, needles, syringes, dressings, tape, Heparin
Sodium (parenteral only), volumetric monitors (parenteral only), and parenteral and
enteral nutrient solutions. Baby food and other regular grocery products that can be
blenderized and used with the enteral system are not covered. Note that some of these
items, e.g., a food pump and an I.V. pole, qualify as DME. Although coverage of the
enteral and parenteral nutritional therapy systems is provided on the basis of the
prosthetic device benefit, the payment rules relating to lump sum or monthly payment for
DME apply to such items.
The coverage of prosthetic devices includes replacement of and repairs to such devices as
explained in subsection D.
Finally, the Benefits Improvement and Protection Act of 2000 amended §1834(h)(1) of
the Act by adding a provision (1834 (h)(1)(G)(i)) that requires Medicare payment to be
made for the replacement of prosthetic devices which are artificial limbs, or for the
replacement of any part of such devices, without regard to continuous use or useful
lifetime restrictions if an ordering physician determines that the replacement device, or
replacement part of such a device, is necessary.
Payment may be made for the replacement of a prosthetic device that is an artificial limb,
or replacement part of a device if the ordering physician determines that the replacement
device or part is necessary because of any of the following:
1. A change in the physiological condition of the patient;
2. An irreparable change in the condition of the device, or in a part of the device; or
3. The condition of the device, or the part of the device, requires repairs and the cost
of such repairs would be more than 60 percent of the cost of a replacement device,
or, as the case may be, of the part being replaced.
This provision is effective for items replaced on or after April 1, 2001. It supersedes any
rule that that provided a 5-year or other replacement rule with regard to prosthetic
devices.
B. Prosthetic Lenses
The term “internal body organ” includes the lens of an eye. Prostheses replacing the lens
of an eye include post-surgical lenses customarily used during convalescence from eye
surgery in which the lens of the eye was removed. In addition, permanent lenses are also
covered when required by an individual lacking the organic lens of the eye because of
surgical removal or congenital absence. Prosthetic lenses obtained on or after the
beneficiary’s date of entitlement to supplementary medical insurance benefits may be
covered even though the surgical removal of the crystalline lens occurred before
entitlement.
1. Prosthetic Cataract Lenses
One of the following prosthetic lenses or combinations of prosthetic lenses furnished by a
physician (see §30.4 for coverage of prosthetic lenses prescribed by a doctor of
optometry) may be covered when determined to be reasonable and necessary to restore
essentially the vision provided by the crystalline lens of the eye:
• Prosthetic bifocal lenses in frames;
• Prosthetic lenses in frames for far vision, and prosthetic lenses in frames for
near vision; or
• When a prosthetic contact lens(es) for far vision is prescribed (including cases
of binocular and monocular aphakia), make payment for the contact lens(es)
and prosthetic lenses in frames for near vision to be worn at the same time as
the contact lens(es), and prosthetic lenses in frames to be worn when the
contacts have been removed.
Lenses which have ultraviolet absorbing or reflecting properties may be covered, in lieu
of payment for regular (untinted) lenses, if it has been determined that such lenses are
medically reasonable and necessary for the individual patient.
Medicare does not cover cataract sunglasses obtained in addition to the regular (untinted)
prosthetic lenses since the sunglasses duplicate the restoration of vision function
performed by the regular prosthetic lenses.
2. Payment for Intraocular Lenses (IOLs) Furnished in Ambulatory Surgical
Centers (ASCs)
Effective for services furnished on or after March 12, 1990, payment for intraocular
lenses (IOLs) inserted during or subsequent to cataract surgery in a Medicare certified
ASC is included with the payment for facility services that are furnished in connection
with the covered surgery.
Refer to the Medicare Claims Processing Manual, Chapter 14, “Ambulatory Surgical
Centers,” for more information.
3. Limitation on Coverage of Conventional Lenses
One pair of conventional eyeglasses or conventional contact lenses furnished after each
cataract surgery with insertion of an IOL is covered.
C. Dentures
Dentures are excluded from coverage. However, when a denture or a portion of the
denture is an integral part (built-in) of a covered prosthesis (e.g., an obturator to fill an
opening in the palate), it is covered as part of that prosthesis.
D. Supplies, Repairs, Adjustments, and Replacement
Supplies are covered that are necessary for the effective use of a prosthetic device (e.g.,
the batteries needed to operate an artificial larynx). Adjustment of prosthetic devices
required by wear or by a change in the patient’s condition is covered when ordered by a
physician. General provisions relating to the repair and replacement of durable medical
equipment in §110.2 for the repair and replacement of prosthetic devices are applicable.
(See the Medicare Benefit Policy Manual, Chapter 16, “General Exclusions from
Coverage,” §40.4, for payment for devices replaced under a warranty.) Replacement of
conventional eyeglasses or contact lenses furnished in accordance with §120.B.3 is not
covered.
Necessary supplies, adjustments, repairs, and replacements are covered even when the
device had been in use before the user enrolled in Part B of the program, so long as the
device continues to be medically required.
130 - Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs,
Arms, and Eyes
(Rev. 1, 10-01-03)
B3-2133, A3-3110.5, HO-228.5, AB-01-06 dated 1/18/01
These appliances are covered under Part B when furnished incident to physicians’
services or on a physician’s order. A brace includes rigid and semi-rigid devices which
are used for the purpose of supporting a weak or deformed body member or restricting or
eliminating motion in a diseased or injured part of the body. Elastic stockings, garter
belts, and similar devices do not come within the scope of the definition of a brace. Back
braces include, but are not limited to, special corsets, e.g., sacroiliac, sacrolumbar,
dorsolumbar corsets, and belts. A terminal device (e.g., hand or hook) is covered under
this provision whether an artificial limb is required by the patient. Stump stockings and
harnesses (including replacements) are also covered when these appliances are essential
to the effective use of the artificial limb.
Adjustments to an artificial limb or other appliance required by wear or by a change in
the patient’s condition are covered when ordered by a physician.
Adjustments, repairs and replacements are covered even when the item had been in use
before the user enrolled in Part B of the program so long as the device continues to be
medically required.
140 - Therapeutic Shoes for Individuals with Diabetes
(Rev. 241, Issued: 02-02-18, Effective: 04-01-18, Implementation: 04-02-18)
Coverage of therapeutic shoes (depth or custom-molded) along with inserts for
individuals with diabetes is available as of May 1, 1993. These diabetic shoes are
covered if the requirements as specified in this section concerning certification and
prescription are fulfilled. In addition, this benefit provides for a pair of diabetic shoes
even if only one foot suffers from diabetic foot disease. Each shoe is equally equipped so
that the affected limb, as well as the remaining limb, is protected. Claims for therapeutic
shoes for diabetics are processed by the Durable Medical Equipment Medicare
Administrative Contractors (DME MACs).
Therapeutic shoes for diabetics are not DME and are not considered DME nor orthotics,
but a separate category of coverage under Medicare Part B. (See §1861(s)(12) and
§1833(o) of the Act.)
A. Definitions
The following items may be covered under the diabetic shoe benefit:
1. Custom-Molded Shoes
Custom-molded shoes are shoes that:
• Are constructed over a positive model of the patient’s foot;
• Are made from leather or other suitable material of equal quality;
• Have removable inserts that can be altered or replaced as the patient’s
condition warrants; and
• Have some form of shoe closure.
2. Depth Shoes
Depth shoes are shoes that:
• Have a full length, heel-to-toe filler that, when removed, provides a minimum
of 3/16 inch of additional depth used to accommodate custom-molded or
customized inserts;
• Are made from leather or other suitable material of equal quality;
• Have some form of shoe closure; and
• Are available in full and half sizes with a minimum of three widths so that the
sole is graded to the size and width of the upper portions of the shoes
according to the American standard last sizing schedule or its equivalent. (The
American standard last sizing schedule is the numerical shoe sizing system
used for shoes sold in the United States.)
3. Inserts
Inserts are total contact, multiple density, removable inlays that are directly molded to
the patient’s foot or a model of the patient’s foot or directly carved from a patient-
specific, rectified electronic model and that are made of a suitable material with
regard to the patient’s condition.
B. Coverage
1. Limitations
For each individual, coverage of the footwear and inserts is limited to one of the
following within one calendar year:
• No more than one pair of custom-molded shoes (including inserts provided
with such shoes) and two additional pairs of inserts; or
• No more than one pair of depth shoes and three pairs of inserts (not including
the noncustomized removable inserts provided with such shoes).
2. Coverage of Diabetic Shoes and Brace
Orthopedic shoes, as stated in the Medicare Claims Processing Manual, Chapter 20,
“Durable Medical Equipment, Surgical Dressings and Casts, Orthotics and Artificial
Limbs, and Prosthetic Devices,” generally are not covered. This exclusion does not
apply to orthopedic shoes that are an integral part of a leg brace. In situations in
which an individual qualifies for both diabetic shoes and a leg brace, these items are
covered separately. Thus, the diabetic shoes may be covered if the requirements for
this section are met, while the brace may be covered if the requirements of §130 are
met.
3. Substitution of Modifications for Inserts
An individual may substitute modification(s) of custom-molded or depth shoes
instead of obtaining a pair(s) of inserts in any combination. Payment for the
modification(s) may not exceed the limit set for the inserts for which the individual is
entitled. The following is a list of the most common shoe modifications available, but
it is not meant as an exhaustive list of the modifications available for diabetic shoes:
• Rigid Rocker Bottoms - These are exterior elevations with apex positions for
51 percent to 75 percent distance measured from the back end of the heel.
The apex is a narrowed or pointed end of an anatomical structure. The apex
must be positioned behind the metatarsal heads and tapered off sharply to the
front tip of the sole. Apex height helps to eliminate pressure at the metatarsal
heads. Rigidity is ensured by the steel in the shoe. The heel of the shoe tapers
off in the back in order to cause the heel to strike in the middle of the heel;
• Roller Bottoms (Sole or Bar) - These are the same as rocker bottoms, but the
heel is tapered from the apex to the front tip of the sole;
• Metatarsal Bars - An exterior bar is placed behind the metatarsal heads in
order to remove pressure from the metatarsal heads. The bars are of various
shapes, heights, and construction depending on the exact purpose;
• Wedges (Posting) - Wedges are either of hind foot, fore foot, or both and may
be in the middle or to the side. The function is to shift or transfer weight
bearing upon standing or during ambulation to the opposite side for added
support, stabilization, equalized weight distribution, or balance; and
• Offset Heels - This is a heel flanged at its base either in the middle, to the
side, or a combination, that is then extended upward to the shoe in order to
stabilize extreme positions of the hind foot.
Other modifications to diabetic shoes include, but are not limited to flared heels,
Velcro closures, and inserts for missing toes.
4. Separate Inserts
Inserts may be covered and dispensed independently of diabetic shoes if the supplier
of the shoes verifies in writing that the patient has appropriate footwear into which
the insert can be placed. This footwear must meet the definitions found above for
depth shoes and custom-molded shoes.
C. Certification
The need for diabetic shoes must be certified by a physician who is a doctor of medicine
or a doctor of osteopathy and who is responsible for diagnosing and treating the patient’s
diabetic systemic condition through a comprehensive plan of care. This managing
physician must:
• Document in the patient’s medical record that the patient has diabetes;
• Certify that the patient is being treated under a comprehensive plan of care for
diabetes, and that the patient needs diabetic shoes; and
• Document in the patient’s record that the patient has one or more of the following
conditions:
o Peripheral neuropathy with evidence of callus formation;
o History of pre-ulcerative calluses;
o History of previous ulceration;
o Foot deformity;
o Previous amputation of the foot or part of the foot; or
o Poor circulation.
D. Prescription
Following certification by the physician managing the patient’s systemic diabetic
condition, a podiatrist or other qualified physician who is knowledgeable in the fitting of
diabetic shoes and inserts may prescribe the particular type of footwear necessary.
E. Furnishing Footwear
The footwear must be fitted and furnished by a podiatrist or other qualified individual
such as a pedorthist, an orthotist, or a prosthetist. The certifying physician may not
furnish the diabetic shoes unless the certifying physician is the only qualified individual
in the area. It is left to the discretion of each A/B MAC (B) to determine the meaning of
“in the area.”
145 - Lymphedema Compression Treatment Items
(Rev. 12532, Issued: 03-07-24, Effective: 01-01-24, Implementation: 05-06-24)
A. General
Coverage of lymphedema compression treatment items is available as of January 1, 2024
for treating beneficiaries with any diagnosis of lymphedema. The lymphedema
compression treatment items must be prescribed by a physician (or a physician assistant,
nurse practitioner, or a clinical nurse specialist (as those terms are defined in section
1861(aa)(5) of the Act) to the extent authorized under State law). Coverage of
lymphedema compression treatment items for any non-lymphedema diagnosis is not
allowed. The items must be furnished by an enrolled DMEPOS supplier. All suppliers,
including physical therapists and other practitioners furnishing bandaging systems must
be enrolled as a DMEPOS supplier to be paid under Medicare Part B for furnishing
lymphedema compression treatment items.
The following categories of lymphedema compression treatment items are covered
when determined to be reasonable and necessary for the treatment of lymphedema:
1. Standard daytime gradient compression garments
2. Custom daytime gradient compression garments
3. Nighttime gradient compression garments
4. Gradient compression wraps with adjustable straps
5. Accessories (e.g., zippers, linings, padding or fillers, etc.) necessary for
the effective use of a gradient compression garment or wrap
6. Compression bandaging supplies
7. Other items determined by CMS to be lymphedema compression
treatment items under the benefit category determination process
established under 42 CFR § 414.1670. These procedures consider public
consultation via public meetings and in writing for new lymphedema
compression treatment items.
With respect to lymphedema compression treatment items:
1. Custom fitted gradient compression garment means a garment that is uniquely
sized and shaped to fit the exact dimensions of the affected extremity or part of
the body, of an individual to provide accurate gradient compression to treat
lymphedema.
2. Gradient compression means the ability to apply a higher level of compression or
pressure to the distal (farther) end of the limb or body part affected by
lymphedema with lower, decreasing compression or pressure at the proximal (closer) end
of the limb or body part affected by lymphedema.
B. Replacements and Frequency Limitations
Payment for replacement of lymphedema compression treatment items can be made for
garments or wraps that are lost, stolen, or irreparably damaged.
If a patient’s medical condition has changed enough to warrant the need for a new size or
type of garment or wrap, payment can be made for the new garment or wrap.
Except for replacements of lymphedema compression treatment items addressed above,
no payment may be made for gradient compression garments or wraps with adjustable
straps furnished other than at the following frequencies:
(1) Three units of daytime gradient compression garments or wraps with
adjustable straps per affected extremity or part of the body once every 6
months.
(2) Two garments for nighttime use per affected extremity or part of the body
once every two years.
There are no set frequency limitations for compression bandaging supplies. The DME
MACs have discretion to determine the replacement and frequency of compression
bandaging supplies that are reasonable and necessary.
150 - Dental Services
(Rev. 11995; Issued: 04-21-23; Effective: 01-01-23; Implementation: 05-12-23)
As indicated under the general exclusions from coverage in 42 CFR 411.15(i), and subject to
exceptions, items and services in connection with the care, treatment, filling, removal, or
replacement of teeth or structures directly supporting the teeth are not covered. “Structures
directly supporting the teeth” means the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. Two
statutory exceptions to this policy allow for Medicare payment for inpatient hospital services in
connection with the provision of dental services if the individual, because of the individual’s
underlying medical condition and clinical status or because of the severity of the dental
procedure, requires hospitalization in connection with the provision of such services.
There are some other instances where medical services necessary to diagnose and treat the
individual’s underlying medical condition may require the performance of certain dental services
and the dental exclusion may not apply. Dental services that are inextricably linked to, and
substantially related and integral to the clinical success of, certain covered medical services are
not excluded. Such non-excluded dental services could include dental and oral examinations as
well as medically necessary diagnostic and treatment services to eliminate an oral or dental
infection. We note that the necessary treatment to eradicate an infection may not include the
totality of recommended dental services for a given patient. For example, if an infected tooth is
identified in a patient requiring an organ transplant, cardiac valve replacement, or valvuloplasty
procedure, the necessary treatment would be to eradicate the infection, which could result in the
tooth being extracted. Additional dental services, such as a dental implant or crown, may not be
considered immediately necessary to eliminate or eradicate the infection or its source prior to
surgery. Therefore, such additional services would not be inextricably linked to, and
substantially related and integral to the clinical success of, the organ transplant, cardiac valve
replacement, or valvuloplasty services. As such, no Medicare payment would be made for the
additional services that are not immediately necessary prior to surgery to eliminate or eradicate
the infection.
Payment may be made under Medicare Parts A and B for dental services, prior to or, in certain
circumstances, contemporaneously with, certain covered medical services furnished in the
inpatient or outpatient setting. Scenarios in which Medicare payment for dental services is not
excluded include, but are not limited to, the examples below.
EXAMPLE 1:
Dental or oral examination performed as part of a comprehensive workup in either the inpatient
or outpatient setting prior to Medicare-covered organ transplant, cardiac valve replacement, or
valvuloplasty procedures; and, medically necessary diagnostic and treatment services to
eliminate an oral or dental infection prior to, or contemporaneously with, the organ transplant,
cardiac valve replacement, or valvuloplasty procedure. For purposes of this manual only,
hematopoietic stem cell and bone marrow transplants have a similar risk of infection to organ
transplants, and an oral examination and subsequent necessary diagnostic and treatment services,
performed in either the inpatient or outpatient setting would be payable under this example. (The
term “organ transplant” may not be considered to include bone marrow or hematopoietic stem
cell transplants in all contexts. These services are not considered organs for purposes of the
definition of organs in 42 CFR 486.302 or Medicare payment policies for organ procurement
organizations.)
EXAMPLE 2:
The reconstruction of a ridge performed as a result of and at the same time as the surgical
removal of a tumor. The reconstruction of a ridge performed primarily to prepare the mouth for
dentures is a noncovered procedure.
EXAMPLE 3:
The stabilization or immobilization of teeth in connection with the reduction of a jaw fracture,
and dental splints only when used in conjunction with covered treatment of a covered medical
condition such as dislocated jaw joints.
EXAMPLE 4:
The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease.
See Pub 100-01, the Medicare General Information, Eligibility, and Entitlement Manual, Chapter
5, Definitions for provisions applicable to doctors of dental surgery or dental medicine.
CMS makes payment for covered dental services furnished by a physician, including a doctor of
dental medicine or dental surgery, or a non-physician practitioner in accordance with state law
and scope of practice in the state where the service is furnished.
Medicare Part A and Part B payment is made for dental services that are inextricably linked to,
and substantially related and integral to the clinical success of, certain covered medical services.
Integration between the health care professionals furnishing dental and other covered services is
a key component in assessing whether dental services are inextricably linked to, and substantially
related and integral to the clinical success of, other covered medical services. This integration
could take the form of a referral or other exchange of information between the physicians, non-
physician practitioners, or other practitioners involved in the delivery of dental and other covered
medical services.
This coordination should occur between the health care professionals furnishing the dental and
other covered services regardless of whether both individuals are affiliated with or employed by
the same entity. If there is no exchange of information, or integration, between the health care
professionals regarding the dental services, then there would not be an inextricable link between
the dental and covered medical services within the meaning of our regulation at § 411.15(i)(3).
This is because the professionals would not have the necessary information to decide that the
dental service(s) is inextricably linked to a covered medical service, and therefore, not subject to
the statutory payment exclusion under section 1862(a)(12) of the Act.
Payment may also be made for covered dental services and supplies furnished incident to the
professional services of the billing physician or practitioner by auxiliary personnel. For example,
services performed by a dental technician, dental hygienist, dental therapist, or registered nurse
who is under the direct supervision of the physician, including a dentist, are covered if the
services meet the requirements for “incident to” services as described in 42 CFR § 410.26.
Ancillary services and supplies furnished incident to covered dental services are also not
excluded, and Medicare payment may be made under Part A or Part B, as applicable, regardless
of whether the service is performed in the inpatient or outpatient setting, including, but not
limited to the administration of anesthesia, diagnostic x-rays, use of operating room, and other
related, otherwise covered procedures.
No payment is made for dental services that may be inextricably linked to, and substantially
related and integral to the clinical success of other non-covered services. Such services remain
subject to the statutory exclusion at § 1862(a)(12) for items and services in connection with the
care, treatment, filling, removal, or replacement of teeth or structures directly supporting the
teeth. More specifically, dental services inextricably linked to a non-covered medical service(s)
are not covered or payable. For example, an alveoplasty (the surgical improvement of the shape
and condition of the alveolar process) and frenectomy are excluded from coverage when either of
these procedures is performed in connection with an excluded service, e.g., the preparation of the
mouth for dentures. Similarly, with rare exception, the removal of a torus palatinus (a bony
protuberance of the hard palate) is performed in connection with an excluded service, i.e., the
preparation of the mouth for dentures. Under such circumstances, Medicare does not pay for this
procedure.
MACs have the flexibility to determine on a claim-by-claim basis whether a patient’s
circumstances do or do not fit within the terms of the statutory preclusion or exceptions specified
in section 1862(a)(12) of the Act and our regulation at 42 CFR § 411.15(i). These policies do
not prevent a MAC from making a determination that payment can be made for dental services in
other circumstances under which the dental services are inextricably linked to, and substantially
related and integral to the clinical success of, certain covered medical services, but are not
specifically addressed in final rules, manual provisions, and the finalized amendments to§
411.15(i).
150.1 - Treatment of Temporomandibular Joint (TMJ) Syndrome
(Rev. 1, 10-01-03)
PASS memo Read.014
There are a wide variety of conditions that can be characterized as TMJ, and an equally
wide variety of methods for treating these conditions. Many of the procedures fall within
the Medicare program’s statutory exclusion that prohibits payment for items and services
that have not been demonstrated to be reasonable and necessary for the diagnosis and
treatment of illness or injury (§1862(a)(1) of the Act). Other services and appliances
used to treat TMJ fall within the Medicare program’s statutory exclusion at 1862(a)(12),
which prohibits payment “for services in connection with the care, treatment, filling,
removal, or replacement of teeth or structures directly supporting teeth....” For these
reasons, a diagnosis of TMJ on a claim is insufficient. The actual condition or symptom
must be determined.
160 - Clinical Psychologist Services
(Rev. 51, Issued: 06-23-06, Effective: 01-01-05, Implementation: 09-21-06)
A. Clinical Psychologist (CP) Defined
To qualify as a clinical psychologist (CP), a practitioner must meet the following
requirements:
Hold a doctoral degree in psychology;
Be licensed or certified, on the basis of the doctoral degree in psychology, by the State in
which he or she practices, at the independent practice level of psychology to furnish
diagnostic, assessment, preventive, and therapeutic services directly to individuals.
B. Qualified Clinical Psychologist Services Defined
Effective July 1, 1990, the diagnostic and therapeutic services of CPs and services and
supplies furnished incident to such services are covered as the services furnished by a
physician or as incident to physician’s services are covered. However, the CP must be
legally authorized to perform the services under applicable licensure laws of the State in
which they are furnished.
C. Types of Clinical Psychologist Services That May Be Covered
Diagnostic and therapeutic services that the CP is legally authorized to perform in
accordance with State law and/or regulation. A/B MACs (B) pay all qualified CPs based
on the physician fee schedule for the diagnostic and therapeutic services. (Psychological
tests by practitioners who do not meet the requirements for a CP may be covered under
the provisions for diagnostic tests as described in §80.2.
Services and supplies furnished incident to a CP’s services are covered if the
requirements that apply to services incident to a physician’s services, as described in §60
are met. These services must be:
• Mental health services that are commonly furnished in CPs’ offices;
• An integral, although incidental, part of professional services performed by the
CP;
• Performed under the direct personal supervision of the CP; i.e., the CP must be
physically present and immediately available;
• Furnished without charge or included in the CP’s bill; and
• Performed by an employee of the CP (or an employee of the legal entity that
employs the supervising CP) under the common law control test of the Act, as set
forth in 20 CFR 404.1007 and §RS 2101.020 of the Retirement and Survivors
Insurance part of the Social Security Program Operations Manual System.
• Diagnostic psychological testing services when furnished under the general
supervision of a CP.
A/B MACs (B) are required to familiarize themselves with appropriate State laws and/or
regulations governing a CP’s scope of practice.
D. Noncovered Services
The services of CPs are not covered if the service is otherwise excluded from Medicare
coverage even though a clinical psychologist is authorized by State law to perform them.
For example, §1862(a)(1)(A) of the Act excludes from coverage services that are not
“reasonable and necessary for the diagnosis or treatment of an illness or injury or to
improve the functioning of a malformed body member.” Therefore, even though the
services are authorized by State law, the services of a CP that are determined to be not
reasonable and necessary are not covered. Additionally, any therapeutic services that are
billed by CPs under CPT psychotherapy codes that include medical evaluation and
management services are not covered.
E. Requirement for Consultation
When applying for a Medicare provider number, a CP must submit to the A/B MAC (B)
a signed Medicare provider/supplier enrollment form that indicates an agreement to the
effect that, contingent upon the patient’s consent, the CP will attempt to consult with the
patient’s attending or primary care physician in accordance with accepted professional
ethical norms, taking into consideration patient confidentiality.
If the patient assents to the consultation, the CP must attempt to consult with the patient’s
physician within a reasonable time after receiving the consent. If the CP’s attempts to
consult directly with the physician are not successful, the CP must notify the physician
within a reasonable time that he or she is furnishing services to the patient. Additionally,
the CP must document, in the patient’s medical record, the date the patient consented or
declined consent to consultations, the date of consultation, or, if attempts to consult did
not succeed, that date and manner of notification to the physician.
The only exception to the consultation requirement for CPs is in cases where the patient’s
primary care or attending physician refers the patient to the CP. Also, neither a CP nor a
primary care nor attending physician may bill Medicare or the patient for this required
consultation.
F. Outpatient Mental Health Services Limitation
All covered therapeutic services furnished by qualified CPs are subject to the outpatient
mental health services limitation in Pub 100-01, Medicare General Information,
Eligibility, and Entitlement Manual, Chapter 3, “Deductibles, Coinsurance Amounts, and
Payment Limitations,” §30, (i.e., only 62 1/2 percent of expenses for these services are
considered incurred expenses for Medicare purposes). The limitation does not apply to
diagnostic services.
G. Assignment Requirement
Assignment is required.
170 - Clinical Social Worker (CSW) Services
(Rev. 1, 10-01-03)
B3-2152
See the Medicare Claims Processing Manual Chapter 12, Physician/Nonphysician
Practitioners, §150, “Clinical Social Worker Services,” for payment requirements.
A. Clinical Social Worker Defined
Section 1861(hh) of the Act defines a “clinical social worker” as an individual who:
• Possesses a master’s or doctor’s degree in social work;
• Has performed at least two years of supervised clinical social work; and
• Is licensed or certified as a clinical social worker by the State in which the
services are performed; or
• In the case of an individual in a State that does not provide for licensure or
certification, has completed at least 2 years or 3,000 hours of post master’s degree
supervised clinical social work practice under the supervision of a master’s level
social worker in an appropriate setting such as a hospital, SNF, or clinic.
B. Clinical Social Worker Services Defined
Section 1861(hh)(2) of the Act defines “clinical social worker services” as those services
that the CSW is legally authorized to perform under State law (or the State regulatory
mechanism provided by State law) of the State in which such services are performed for
the diagnosis and treatment of mental illnesses. Services furnished to an inpatient of a
hospital or an inpatient of a SNF that the SNF is required to provide as a requirement for
participation are not included. The services that are covered are those that are otherwise
covered if furnished by a physician or as incident to a physician’s professional service.
C. Covered Services
Coverage is limited to the services a CSW is legally authorized to perform in accordance
with State law (or State regulatory mechanism established by State law). The services of
a CSW may be covered under Part B if they are:
• The type of services that are otherwise covered if furnished by a physician, or as
incident to a physician’s service. (See §30 for a description of physicians’
services and §70 of Pub 100-1, the Medicare General Information, Eligibility, and
Entitlement Manual, Chapter 5, for the definition of a physician.);
• Performed by a person who meets the definition of a CSW (See subsection A.);
and
• Not otherwise excluded from coverage.
A/B MACs (B) should become familiar with the State law or regulatory mechanism
governing a CSW’s scope of practice in their service area.
D. Noncovered Services
Services of a CSW are not covered when furnished to inpatients of a hospital or to
inpatients of a SNF if the services furnished in the SNF are those that the SNF is required
to furnish as a condition of participation in Medicare. In addition, CSW services are not
covered if they are otherwise excluded from Medicare coverage even though a CSW is
authorized by State law to perform them. For example, the Medicare law excludes from
coverage services that are not “reasonable and necessary for the diagnosis or treatment of
an illness or injury or to improve the functioning of a malformed body member.”
E. Outpatient Mental Health Services Limitation
All covered therapeutic services furnished by qualified CSWs are subject to the
outpatient psychiatric services limitation in Pub 100-01, Medicare General Information,
Eligibility, and Entitlement Manual, Chapter 3, “Deductibles, Coinsurance Amounts, and
Payment Limitations,” §30, (i.e., only 62 1/2 percent of expenses for these services are
considered incurred expenses for Medicare purposes). The limitation does not apply to
diagnostic services.
F. Assignment Requirement
Assignment is required.
180 - Nurse-Midwife (CNM) Services
(Rev. 10639; Issued: 03-12-2021; Effective: 01-01-2021; Implementation: 04-12-
2021)
A. General
Effective on or after July 1, 1988, the services provided by a certified nurse-midwife or
incident to the certified nurse-midwife’s services are covered. Payment is made under
assignment only.
See the Medicare Claims Processing Manual, Chapter 12, “Physician and Nonphysician
Practitioners,” §130, for payment methodology for nurse midwife services.
B. Certified Nurse-Midwife Defined
A certified nurse-midwife is a registered nurse who has successfully completed a
program of study and clinical experience in nurse-midwifery, meeting guidelines
prescribed by the Secretary, or who has been certified by an organization recognized by
the Secretary. The Secretary has recognized certification by the American College of
Nurse-Midwives and State qualifying requirements in those States that specify a program
of education and clinical experience for nurse-midwives for these purposes. A nurse-
midwife must:
• Be currently licensed to practice in the State as a registered professional nurse;
and
• Meet one of the following requirements:
1. Be legally authorized under State law or regulations to practice as a nurse-
midwife and have completed a program of study and clinical experience
for nurse-midwives, as specified by the State; or
2. If the State does not specify a program of study and clinical experience
that nurse-midwives must complete to practice in that State, the nurse-
midwife must:
a. Be currently certified as a nurse-midwife by the American College
of Nurse-Midwives;
b. Have satisfactorily completed a formal education program (of at
least one academic year) that, upon completion, qualifies the nurse
to take the certification examination offered by the American
College of Nurse-Midwives; or
c. Have successfully completed a formal education program for
preparing registered nurses to furnish gynecological and obstetrical
care to women during pregnancy, delivery, and the postpartum
period, and care to normal newborns, and have practiced as a
nurse-midwife for a total of 12 months during any 18-month period
from August 8, 1976, to July 16, 1982.
C. Covered Services
1. General - Effective January 1, 1988, through December 31, 1993, the coverage of
nurse-midwife services was restricted to the maternity cycle. The maternity cycle is a
period that includes pregnancy, labor, and the immediate postpartum period.
Beginning with services furnished on or after January 1, 1994, coverage is no longer
limited to the maternity cycle. Coverage is available for services furnished by a nurse-
midwife that he or she is legally authorized to perform in the State in which the services
are furnished and that would otherwise be covered if furnished by a physician, including
obstetrical and gynecological services.
2. Incident To - Services and supplies furnished incident to a nurse midwife’s service
are covered if they would have been covered when furnished incident to the services of a
doctor of medicine or osteopathy, as described in §60.
3. Medical Record Documentation for Part B Services –This medical record
documentation requirement applies to Part B professional services that are paid under the
Medicare physician fee schedule. Accordingly, for Part B certified nurse-midwives
covered services, the certified nurse-midwife may review and verify (sign and date),
rather than re-document notes in a patient’s medical record made by physicians,
residents, nurses, medical; physician assistant; nurse practitioner; clinical nurse specialist;
certified nurse-midwife; and certified registered nurse anesthetist students or other
members of the medical team, including as applicable, notes documenting the certified
nurse-midwives presence and participation in the service.
For documentation requirements specific to E/M services furnished by physicians and
certain nonphysician practitioners, see Chapter 12, section 30.6 of the Medicare Claims
Processing Manual, publication 100-04.
D. Noncovered Services
The services of nurse-midwives are not covered if they are otherwise excluded from
Medicare coverage even though a nurse-midwife is authorized by State law to perform
them. For example, the Medicare program excludes from coverage routine physical
checkups and services that are not reasonable and necessary for the diagnosis or
treatment of an illness or injury or to improve the functioning of a malformed body
member.
Coverage of service to the newborn continues only to the point that the newborn is or
would normally be treated medically as a separate individual. Items and services
furnished the newborn from that point are not covered on the basis of the mother’s
eligibility.
E. Relationship With Physician
Most States have licensure and other requirements applicable to nurse-midwives. For
example, some require that the nurse-midwife have an arrangement with a physician for
the referral of the patient in the event a problem develops that requires medical attention.
Others may require that the nurse-midwife function under the general supervision of a
physician. Although these and similar State requirements must be met in order for the
nurse-midwife to provide Medicare covered care, they have no effect on the nurse-
midwife’s right to personally bill for and receive direct Medicare payment. That is,
billing does not have to flow through a physician or facility.
See §60.2 for coverage of services performed by nurse-midwives incident to the service
of physicians.
F. Place of Service
There is no restriction on place of service. Therefore, nurse-midwife services are covered
if provided in the nurse-midwife’s office, in the patient’s home, or in a hospital or other
facility, such as a clinic or birthing center owned or operated by a nurse-midwife.
G. Assignment Requirement
Assignment is required.
190 - Physician Assistant (PA) Services
(Rev. 11288; Issued: 03-04-22; Effective: 01-01-22; Implementation: 02-15-22)
Effective for services rendered on or after January 1, 1998, any individual who is
participating under the Medicare program as a physician assistant for the first time may
have his or her professional services covered if he or she meets the qualifications listed
below and he or she is legally authorized to furnish PA services in the State where the
services are performed. PAs who were issued billing provider numbers prior to
January 1, 1998 may continue to furnish services under the PA benefit.
See the Medicare Claims Processing Manual, Chapter 12, “Physician and Nonphysician
Practitioners,” §110, for payment methodology for PA services. Payment is made under
assignment only.
A. Qualifications for PAs
To furnish covered PA services, the PA must meet the conditions as follows:
1. Have graduated from a physician assistant educational program that is accredited
by the Accreditation Review Commission on Education for the Physician Assistant
(its predecessor agencies, the Commission on Accreditation of Allied Health
Education Programs (CAAHEP) and the Committee on Allied Health Education and
Accreditation (CAHEA); or
2. Have passed the national certification examination that is administered by the
National Commission on Certification of Physician Assistants (NCCPA); and
3. Be licensed by the State to practice as a physician assistant.
B. Covered Services
Coverage is limited to the services a PA is legally authorized to perform in accordance
with State law (or State regulatory mechanism provided by State law).
1. General
The services of a PA may be covered under Part B, if all of the following requirements
are met:
• They are the type that are considered physician’s services if furnished by a
doctor of medicine or osteopathy (MD/DO);
• They are performed by a person who meets all the PA qualifications,
• They are performed under the general supervision of an MD/DO;
• The PA is legally authorized to perform the services in the state in which they
are performed; and
• They are not otherwise precluded from coverage because of one of the
statutory exclusions.
2. Incident To
If covered PA services are furnished, services and supplies furnished incident to the PA’s
services may also be covered if they would have been covered when furnished incident to
the services of an MD/DO, as described in §60.
3. Medical Record Documentation for Part B Services
This medical record documentation requirement applies to Part B professional services
that are paid under the Medicare physician fee schedule. Accordingly, for Part B
physician assistant covered services, the physician assistant may review and verify (sign
and date), rather than re-document notes in a patient’s medical record made by
physicians, residents, nurses, medical; physician assistant; nurse practitioner; clinical
nurse specialist; certified nurse-midwife; and certified registered nurse anesthetist
students or other members of the medical team, including as applicable, notes
documenting the physician assistant’s presence and participation in the service.
For documentation requirements specific to E/M services furnished by physicians and
certain nonphysician practitioners, see Chapter 12, section 30.6 of the Medicare Claims
Processing Manual, publication 100-04.
4. Types of PA Services That May Be Covered
State law or regulation governing a PA’s scope of practice in the State in which the
services are performed applies. A/B MACs (B) should consider developing lists of
covered services. Also, if authorized under the scope of their State license, PAs may
furnish services billed under all levels of CPT evaluation and management codes, and
diagnostic tests if furnished under the general supervision of a physician.
Examples of the types of services that PAs may provide include services that traditionally
have been reserved to physicians, such as physical examinations, minor surgery, setting
casts for simple fractures, interpreting x-rays, and other activities that involve an
independent evaluation or treatment of the patient’s condition.
See §60.2 for coverage of services performed by PAs incident to the services of
physicians.
5. Services Otherwise Excluded From Coverage
The PA services may not be covered if they are otherwise excluded from coverage even
though a PA may be authorized by State law to perform them. For example, the
Medicare law excludes from coverage routine foot care, routine physical checkups, and
services that are not reasonable and necessary for the diagnosis or treatment of an illness
or injury or to improve the functioning of a malformed body member. Therefore, these
services are precluded from coverage even though they may be within a PA’s scope of
practice under State law.
C. Physician Supervision
The physician supervision requirement under Medicare law is met under the
circumstances as follows:
Medicare Part B covers a PA’s services only if the PA performs the services in
accordance with state law and state scope of practice rules for PAs in the state in which
the PA’s professional services are furnished. Any state laws and scope of practice rules
that describe the required practice relationship between physicians and PA’s, including
explicit supervisory or collaborative practice requirements, describe a form of
supervision for purposes of the PA benefit category under section 1861(s)(2)(K)(i) of the
Act. For states with no explicit state law and scope of practice rules regarding physician
supervision of PA’s services, physician supervision is a process in which a PA has a
working relationship with one or more physicians to supervise the delivery of their health
care services. Such physician supervision is evidenced by documenting at the practice
level the PA’s scope of practice and the working relationships the PA has with the
supervising physician/s when furnishing professional services.
D. Direct Billing and Payment
Effective January 1, 2022, direct billing and payment for PA services may be made to the
PA.
E. Assignment
Assignment for PA services is mandatory.
200 - Nurse Practitioner (NP) Services
(Rev. 11771 ; Issued:12-30-22 ; Effective:01-01-23 ; Implementation:01-01-23 )
Effective for services rendered after January 1, 1998, any individual who is participating
under the Medicare program as a nurse practitioner (NP) for the first time ever, may have
his or her professional services covered if he or she meets the qualifications listed below,
and he or she is legally authorized to furnish NP services in the State where the services
are performed. NPs who were issued billing provider numbers prior to January 1, 1998,
may continue to furnish services under the NP benefit.
Payment for NP services is effective on the date of service, that is, on or after January 1,
1998, and payment is made on an assignment-related basis only.
A. Qualifications for NPs
In order to furnish covered NP services, an NP must meet the conditions as follows:
• Be a registered professional nurse who is authorized by the State in which the
services are furnished to practice as a nurse practitioner in accordance with
State law; and be certified as a nurse practitioner by a recognized national
certifying body that has established standards for nurse practitioners; or
• Be a registered professional nurse who is authorized by the State in which the
services are furnished to practice as a nurse practitioner by December 31,
2000.
The following organizations are recognized national certifying bodies for NPs at the
advanced practice level:
• American Academy of Nurse Practitioners;
• American Nurses Credentialing Center;
• National Certification Corporation for Obstetric, Gynecologic and Neonatal
Nursing Specialties;
• Pediatric Nursing Certification Board (previously named the National
Certification Board of Pediatric Nurse Practitioners and Nurses);
• Oncology Nurses Certification Corporation;
• AACN Certification Corporation;
• National Board on Certification of Hospice and Palliative Nurses; and,
• Nurse Portfolio Credentialing Commission.
The NPs applying for a Medicare billing number for the first time on or after January 1,
2001, must meet the requirements as follows:
• Be a registered professional nurse who is authorized by the State in which the
services are furnished to practice as a nurse practitioner in accordance with
State law; and
• Be certified as a nurse practitioner by a recognized national certifying body
that has established standards for nurse practitioners.
The NPs applying for a Medicare billing number for the first time on or after January 1,
2003, must meet the requirements as follows:
• Be a registered professional nurse who is authorized by the State in which the
services are furnished to practice as a nurse practitioner in accordance with
State law;
• Be certified as a nurse practitioner by a recognized national certifying body
that has established standards for nurse practitioners; and
• Possess a master’s degree in nursing or a doctor of nursing practice (DNP)
doctoral degree.
B. Covered Services
Coverage is limited to the services an NP is legally authorized to perform in accordance
with State law (or State regulatory mechanism established by State law).
1. General
The services of an NP may be covered under Part B if all of the following conditions are
met:
• They are the type that are considered physician’s services if furnished by a
doctor of medicine or osteopathy (MD/DO);
• They are performed by a person who meets the definition of an NP (see
subsection A);
• The NP is legally authorized to perform the services in the State in which they
are performed;
• They are performed in collaboration with an MD/DO (see subsection D); and
• They are not otherwise precluded from coverage because of one of the
statutory exclusions. (See subsection C.2.)
2. Incident To
If covered NP services are furnished, services and supplies furnished incident to the
services of the NP may also be covered if they would have been covered when furnished
incident to the services of an MD/DO as described in §60.
3. Medical Record Documentation for Part B Services
This medical record documentation requirement applies to Part B professional services
that are paid under the Medicare physician fee schedule. Accordingly, for Part B nurse
practitioner covered services, the nurse practitioner may review and verify (sign and
date), rather than re-document notes in a patient’s medical record made by physicians,
residents, nurses, medical; physician assistant; nurse practitioner; clinical nurse specialist;
certified nurse-midwife; and certified registered nurse anesthetist students or other
members of the medical team, including as applicable, notes documenting the nurse
practitioner’s presence and participation in the service.
For documentation requirements specific to E/M services furnished by physicians and
certain nonphysician practitioners, see Chapter 12, section 30.6 of the Medicare Claims
Processing Manual, publication 100-04.
C. Application of Coverage Rules
1. Types of NP Services That May Be Covered
State law or regulation governing an NP’s scope of practice in the State in which the
services are performed applies. Consider developing a list of covered services based on
the State scope of practice. Examples of the types of services that NP’s may furnish
include services that traditionally have been reserved to physicians, such as physical
examinations, minor surgery, setting casts for simple fractures, interpreting x-rays, and
other activities that involve an independent evaluation or treatment of the patient’s
condition. Also, if authorized under the scope of their State license, NPs may furnish
services billed under all levels of evaluation and management codes and diagnostic tests
if furnished in collaboration with a physician.
See §60.2 for coverage of services performed by NPs incident to the services of
physicians.
2. Services Otherwise Excluded From Coverage
The NP services may not be covered if they are otherwise excluded from coverage even
though an NP may be authorized by State law to perform them. For example, the
Medicare law excludes from coverage routine foot care, routine physical checkups, and
services that are not reasonable and necessary for the diagnosis or treatment of an illness
or injury or to improve the functioning of a malformed body member. Therefore, these
services are precluded from coverage even though they may be within an NP’s scope of
practice under State law.
D. Collaboration
Collaboration is a process in which an NP works with one or more physicians (MD/DO)
to deliver health care services, with medical direction and appropriate supervision as
required by the law of the State in which the services are furnished. In the absence of
State law governing collaboration, collaboration is to be evidenced by NPs documenting
their scope of practice and indicating the relationships that they have with physicians to
deal with issues outside their scope of practice.
The collaborating physician does not need to be present with the NP when the services
are furnished or to make an independent evaluation of each patient who is seen by the
NP.
E. Direct Billing and Payment
Direct billing and payment for NP services may be made to the NP.
F. Assignment
Assignment is mandatory.
210 - Clinical Nurse Specialist (CNS) Services
(Rev. 11771 ; Issued:12-30-22 ; Effective:01-01-23 ; Implementation:01-01-23 )
Effective for services rendered after January 1, 1998, any individual who is participating
under the Medicare program as a clinical nurse specialist (CNS) for the first time ever,
may have his or her professional services covered if he or she meets the qualifications
listed below and he or she is legally authorized to furnish CNS services in the State where
the services are performed. CNSs who were issued billing provider numbers prior to
January 1, 1998, may continue to furnish services under the CNS benefit.
Payment for CNS services is effective on the date of service, that is, on or after January 1,
1998, and payment is made on an assignment-related basis only.
A. Qualifications for CNSs
In order to furnish covered CNS services, a CNS must meet the conditions as follows:
1. Be a registered nurse who is currently licensed to practice in the State where he or
she practices and be authorized to furnish the services of a clinical nurse specialist
in accordance with State law;
2. Have a master’s degree in a defined clinical area of nursing from an accredited
educational institution or a doctor of nursing practice (DNP) doctoral degree; and
3. Be certified as a clinical nurse specialist by a recognized national certifying body
that has established standards for CNSs.
The following organizations are recognized national certifying bodies for CNSs at the
advanced practice level:
• American Academy of Nurse Practitioners;
• American Nurses Credentialing Center;
• National Certification Corporation for Obstetric, Gynecologic and Neonatal
Nursing Specialties;
• Pediatric Nursing Certification Board (previously named the National
Certification Board of Pediatric Nurse Practitioners and Nurses);
• Oncology Nurses Certification Corporation;
• AACN Certification Corporation;
• National Board on Certification of Hospice and Palliative Nurses; and,
• Nurse Portfolio Credentialing Commission.
B. Covered Services
Coverage is limited to the services a CNS is legally authorized to perform in accordance
with State law (or State regulatory mechanism provided by State law).
1. General
The services of a CNS may be covered under Part B if all of the following conditions are
met:
• They are the types of services that are considered as physician’s services if
furnished by an MD/DO;
• They are furnished by a person who meets the CNS qualifications (see
subsection A);
• The CNS is legally authorized to furnish the services in the State in which
they are performed;
• They are furnished in collaboration with an MD/DO as required by State law
(see subsection C); and
• They are not otherwise excluded from coverage because of one of the
statutory exclusions. (See subsection C.)
2. Types of CNS Services that May be Covered
State law or regulations governing a CNS’ scope of practice in the State in which the
services are furnished applies. A/B MACs (B) must develop a list of covered services
based on the State scope of practice.
Examples of the types of services that a CNS may furnish include services that
traditionally have been reserved for physicians, such as physical examinations, minor
surgery, setting casts for simple fractures, interpreting x-rays, and other activities that
involve an independent evaluation or treatment of the patient’s condition. Also, if
authorized under the scope of his or her State license, a CNS may furnish services billed
under all levels of evaluation and management codes and diagnostic tests if furnished in
collaboration with a physician.
3. Incident To
If covered CNS services are furnished, services and supplies furnished incident to the
services of the CNS may also be covered if they would have been covered when
furnished incident to the services of an MD/DO as described in §60.
4. Medical Record Documentation for Part B Services
This medical record documentation requirement applies to Part B professional services
that are paid under the Medicare physician fee schedule. Accordingly, for Part B Clinical
Nurse Specialist (CNS) covered services, the CNS may review and verify (sign and date),
rather than re-document notes in a patient’s medical record made by physicians,
residents, nurses, medical; physician assistant; nurse practitioner; clinical nurse specialist;
certified nurse-midwife; and certified registered nurse anesthetist students or other
members of the medical team, including as applicable, notes documenting the CNS’s
presence and participation in the service.
For documentation requirements specific to E/M services furnished by physicians and
certain nonphysician practitioners, see Chapter 12, section 30.6 of the Medicare Claims
Processing Manual, publication 100-04.
C. Application of Coverage Rules
1. Types of CNS Services
Examples of the types of services that CNS may provide are services that traditionally
have been reserved for physicians, such as physical examinations, minor surgery, setting
casts for simple fractures, interpreting x-rays, and other activities that involve an
independent evaluation or treatment of the patient’s condition. State law or regulation
governing a CNS’ scope of practice for his or her service area applies.
2. Services Otherwise Excluded From Coverage
A CNS’ services are not covered if they are otherwise excluded from coverage even
though a CNS may be authorized by State law to perform them. For example, the
Medicare law excludes from coverage routine foot care and routine physical checkups
and services that are not reasonable and necessary for diagnosis or treatment of an illness
or injury or to improve the function of a malformed body member. Therefore, these
services are precluded from coverage even though they may be within a CNS’ scope of
practice under State law.
See §60.2 for coverage of services performed by a CNS incident to the services of
physicians.
D. Collaboration
Collaboration is a process in which a CNS works with one or more physicians (MD/DO)
to deliver health care services within the scope of the CNS’ professional expertise with
medical direction and appropriate supervision as required by the law of the State in which
the services are furnished. In the absence of State law governing collaboration,
collaboration is to be evidenced by the CNS documenting his or her scope of practice and
indicating the relationships that the CNS has with physicians to deal with issues outside
the CNS’ scope of practice.
The collaborating physician does not need to be present with the CNS when the services
are furnished or to make an independent evaluation of each patient who is seen by the
CNS.
E. Direct Billing and Payment
A CNS may bill directly and receive direct payment for their services.
F. Assignment Requirement
Assignment is required for the service to be covered.
220 - Coverage of Outpatient Rehabilitation Therapy Services (Physical
Therapy, Occupational Therapy, and Speech-Language Pathology
Services) Under Medical Insurance
(Rev. 12425; Issued: 12-21-23: Effective: 01-01-24; Implementation: 01-02-24)
A comprehensive knowledge of the policies that apply to therapy services cannot
be obtained through manuals alone. The most definitive policies are Local
Coverage Determinations found at the Medicare Coverage Database
www.cms.hhs.gov/mcd. A list of Medicare contractors is found at the CMS Web
site. Specific questions about all Medicare policies should be addressed to the
contractors through the contact information supplied on their Web sites. General
Medicare questions may be addressed to the Medicare regional offices
http://www.cms.hhs.gov/RegionalOffices/.
A. Definitions
The following defines terms used in this section and §230:
ACTIVE PARTICIPATION of the clinician in treatment means that the
clinician personally furnishes in its entirety at least 1 billable service on at
least 1 day of treatment.
ASSESSMENT is separate from evaluation, and is included in services or
procedures, (it is not separately payable). The term assessment as used in
Medicare manuals related to therapy services is distinguished from language
in Current Procedural Terminology (CPT) codes that specify assessment, e.g.,
97755, Assistive Technology Assessment, which may be payable).
Assessments shall be provided only by clinicians, because assessment requires
professional skill to gather data by observation and patient inquiry and may
include limited objective testing and measurement to make clinical judgments
regarding the patient's condition(s). Assessment determines, e.g., changes in
the patient's status since the last visit/treatment day and whether the planned
procedure or service should be modified. Based on these assessment data, the
professional may make judgments about progress toward goals and/or
determine that a more complete evaluation or re-evaluation (see definitions
below) is indicated. Routine weekly assessments of expected progression in
accordance with the plan are not payable as re-evaluations.
CERTIFICATION is the physician’s/nonphysician practitioner’s (NPP)
approval of the plan of care. Certification requires a dated signature on the
plan of care or some other document that indicates approval of the plan of
care.
The CLINICIAN is a term used in this manual and in Pub 100-04, chapter 5,
section 10 or section 20, to refer to only a physician, nonphysician practitioner
or a therapist (but not to an assistant, aide or any other personnel) providing a
service within their scope of practice and consistent with state and local law.
Clinicians make clinical judgments and are responsible for all services they
are permitted to supervise. Services that require the skills of a therapist, may
be appropriately furnished by clinicians, that is, by or under the supervision of
qualified physicians/NPPs when their scope of practice, state and local laws
allow it and their personal professional training is judged by Medicare
contractors as sufficient to provide to the beneficiary skills equivalent to a
therapist for that service.
COMPLEXITIES are complicating factors that may influence treatment, e.g.,
they may influence the type, frequency, intensity and/or duration of treatment.
Complexities may be represented by diagnoses (ICD codes), by patient factors
such as age, severity, acuity, multiple conditions, and motivation, or by the
patient’s social circumstances such as the support of a significant other or the
availability of transportation to therapy.
A DATE may be in any form (written, stamped or electronic). The date may
be added to the record in any manner and at any time, as long as the dates are
accurate. If they are different, refer to both the date a service was performed
and the date the entry to the record was made. For example, if a physician
certifies a plan and fails to date it, staff may add “Received Date” in writing or
with a stamp. The received date is valid for certification/re-certification
purposes. Also, if the physician faxes the referral, certification, or re-
certification and forgets to date it, the date that prints out on the fax is valid.
If services provided on one date are documented on another date, both dates
should be documented.
The EPISODE of Outpatient Therapy – For the purposes of therapy policy, an
outpatient therapy episode is defined as the period of time, in calendar days,
from the first day the patient is under the care of the clinician (e.g., for
evaluation or treatment) for the current condition(s) being treated by one
therapy discipline (PT, or OT, or SLP) until the last date of service for that
discipline in that setting.
During the episode, the beneficiary may be treated for more than one
condition; including conditions with an onset after the episode has begun. For
example, a beneficiary receiving PT for a hip fracture who, after the initial
treatment session, develops low back pain would also be treated under a PT
plan of care for rehabilitation of low back pain. That plan may be modified
from the initial plan, or it may be a separate plan specific to the low back pain,
but treatment for both conditions concurrently would be considered the same
episode of PT treatment. If that same patient developed a swallowing problem
during intubation for the hip surgery, the first day of treatment by the SLP
would be a new episode of SLP care.
EVALUATION is a separately payable comprehensive service provided by a
clinician, as defined above, that requires professional skills to make clinical
judgments about conditions for which services are indicated based on
objective measurements and subjective evaluations of patient performance and
functional abilities. Evaluation is warranted e.g., for a new diagnosis or when
a condition is treated in a new setting. These evaluative judgments are
essential to development of the plan of care, including goals and the selection
of interventions.
FUNCTIONAL REPORTING, which is required on claims for all outpatient
therapy services pursuant to 42CFR410.59, 410.60, and 410.62, uses
nonpayable G-codes and related modifiers to convey information about the
patient’s functional status at specified points during therapy. (See Pub 100-
04, chapter 5, section 10.6) NOTE: Functional reporting requirements are no
longer applicable for claims for dates of service on and after January 1, 2019.
See the NOTE at the beginning of Section 220.4 for more information about
the discontinuation of functional reporting requirements.
RE-EVALUATION provides additional objective information not included in
other documentation. Re-evaluation is separately payable and is periodically
indicated during an episode of care when the professional assessment of a
clinician indicates a significant improvement, or decline, or change in the
patient's condition or functional status that was not anticipated in the plan of
care. Although some state regulations and state practice acts require re-
evaluation at specific times, for Medicare payment, reevaluations must also
meet Medicare coverage guidelines. The decision to provide a reevaluation
shall be made by a clinician.
INTERVAL of certified treatment (certification interval) consists of 90
calendar days or less, based on an individual’s needs. A physician/NPP may
certify a plan of care for an interval length that is less than 90 days. There
may be more than one certification interval in an episode of care. The
certification interval is not the same as a Progress Report period.
MAINTENANCE PROGRAM (MP) means a program established by a
therapist that consists of activities and/or mechanisms that will assist a
beneficiary in maximizing or maintaining the progress he or she has made
during therapy or to prevent or slow further deterioration due to a disease or
illness.
NONPHYSICIAN PRACTITIONERS (NPP) means physician assistants,
clinical nurse specialists, and nurse practitioners, who may, if state and local
laws permit it, and when appropriate rules are followed, provide, certify or
supervise therapy services.
PHYSICIAN with respect to outpatient rehabilitation therapy services means a
doctor of medicine, osteopathy (including an osteopathic practitioner),
podiatric medicine, or optometry (for low vision rehabilitation only).
Chiropractors and doctors of dental surgery or dental medicine are not
considered physicians for therapy services and may neither refer patients for
rehabilitation therapy services nor establish therapy plans of care.
PATIENT, client, resident, and beneficiary are terms used interchangeably to
indicate enrolled recipients of Medicare covered services.
PROVIDERS of services are defined in §1861(u) of the Act, 42CFR400.202
and 42CFR485 Subpart H as participating hospitals, critical access hospitals
(CAH), skilled nursing facilities (SNF), comprehensive outpatient
rehabilitation facilities (CORF), home health agencies (HHA), hospices,
participating clinics, rehabilitation agencies or outpatient rehabilitation
facilities (ORF). Providers are also defined as public health agencies with
agreements only to furnish outpatient therapy services, or community mental
health centers with agreements only to furnish partial hospitalization or
intensive outpatient services. To qualify as providers of services, these
providers must meet certain conditions enumerated in the law and enter into
an agreement with the Secretary in which they agree not to charge any
beneficiary for covered services for which the program will pay and to refund
any erroneous collections made. Note that the word PROVIDER in sections
220 and 230 is not used to mean a person who provides a service, but is used
as in the statute to mean a facility or agency such as rehabilitation agency or
home health agency.
QUALIFIED PROFESSIONAL means a physical therapist, occupational
therapist, speech-language pathologist, physician, nurse practitioner, clinical
nurse specialist, or physician’s assistant, who is licensed or certified by the
state to furnish therapy services, and who also may appropriately furnish
therapy services under Medicare policies. Qualified professional may also
include a physical therapist assistant (PTA) or an occupational therapy
assistant (OTA) when furnishing services under the supervision of a qualified
therapist, who is working within the state scope of practice in the state in
which the services are furnished. Assistants are limited in the services they
may furnish (see section 230.1 and 230.2) and may not supervise other
therapy caregivers.
QUALIFIED PERSONNEL means staff (auxiliary personnel) who have been
educated and trained as therapists and qualify to furnish therapy services only
under direct supervision incident to a physician or NPP. See §230.5 of this
chapter. Qualified personnel may or may not be licensed as therapists but
meet all of the requirements for therapists with the exception of licensure.
SIGNATURE means a legible identifier of any type acceptable according to
policies in Pub. 100-08, Medicare Program Integrity Manual, chapter 3,
§3.3.2.4 concerning signatures.
SUPERVISION LEVELS for outpatient rehabilitation therapy services are the
same as those for diagnostic tests defined in 42CFR410.32. Depending on the
setting, the levels include personal supervision (in the room), direct
supervision (in the office suite), and general supervision (physician/NPP is
available but not necessarily on the premises).
SUPPLIERS of therapy services include individual practitioners such as
physicians, NPPs, physical therapists and occupational therapists who have
Medicare provider numbers. Regulatory references on physical therapists in
private practice (PTPPs) and occupational therapists in private practice
(OTPPs) are at 42CFR410.60 (C)(1), 485.701729, and 486.150-163.
THERAPIST refers only to qualified physical therapists, occupational
therapists and speech-language pathologists, as defined in §230.
Qualifications that define therapists are in §§230.1, 230.2, and 230.3. Skills
of a therapist are defined by the scope of practice for therapists in the state).
THERAPY (or outpatient rehabilitation services) includes only outpatient
physical therapy (PT), occupational therapy (OT) and speech-language
pathology (SLP) services paid using the Medicare Physician Fee Schedule or
the same services when provided in hospitals that are exempt from the
hospital Outpatient Prospective Payment System and paid on a reasonable cost
basis, including critical access hospitals.
Therapy services referred to in this chapter are those skilled services furnished
according to the standards and conditions in CMS manuals, (e.g., in this
chapter and in Pub. 100-04, Medicare Claims Processing Manual, chapter 5),
within their scope of practice by qualified professionals or qualified personnel,
as defined in this section, represented by procedures found in the American
Medical Association’s “Current Procedural Terminology (CPT).” A list of
CPT (HCPCS) codes is provided in Pub. 100-04, chapter 5, §20, and in Local
Coverage Determinations developed by contractors.
TREATMENT DAY means a single calendar day on which treatment,
evaluation and/or reevaluation is provided. There could be multiple visits,
treatment sessions/encounters on a treatment day.
VISITS OR TREATMENT SESSIONS begin at the time the patient enters the
treatment area (of a building, office, or clinic) and continue until all services
(e.g., activities, procedures, services) have been completed for that session and
the patient leaves that area to participate in a non-therapy activity. It is likely
that not all minutes in the visits/treatment sessions are billable (e.g., rest
periods). There may be two treatment sessions in a day, for example, in the
morning and afternoon. When there are two visits/ treatment sessions in a
day, plans of care indicate treatment amount of twice a day.
B. References
Paper Manuals. The following manuals, now outdated, were resources for the
Internet Only Manuals:
• Part A Medicare Intermediary Manual, (Pub. 13)
• Part B Medicare Carrier Manual, (Pub. 14)
• Hospital Manual, (Pub. 10)
• Outpatient Physical Therapy/CORF Manual, (Pub. 9)
Regulation and Statute. The information in this section is based in part on the
following current references:
• 42CFR refers to Title 42, Code of Federal Regulation (CFR).
• The Act refers to the Social Security Act.
Internet Only Manuals. Current Policies that concern providers and suppliers
of therapy services are located in many places throughout CMS Manuals.
Sites that may be of interest include:
• Pub.100-01 GENERAL INFORMATION, ELIGIBILITY, AND
ENTITLEMENT
o Chapter 1- General Overview
10.1 - Hospital Insurance (Part A) for Inpatient Hospital, Hospice,
Home Health and SNF Services - A Brief Description
10.2 - Home Health Services
10.3 - Supplementary Medical Insurance (Part B) - A Brief
Description
20.2 - Discrimination Prohibited
• Pub. 100-02, MEDICARE BENEFIT POLICY MANUAL
o Ch 6 - Hospital Services Covered Under Part B
10 - Medical and Other Health Services Furnished to Inpatients of
Participating Hospitals
20 - Outpatient Hospital Services
20.2 - Outpatient Defined
20.4.1 - Diagnostic Services Defined
70 - Outpatient Hospital Psychiatric Services
o Ch 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance
30.4. - Direct Skilled Rehabilitation Services to Patients
40 - Physician Certification and Recertification for Extended Care
Services
50.3 - Physical Therapy, Speech-Language Pathology, and
Occupational
Therapy Furnished by the Skilled Nursing Facility or by Others
Under
Arrangements with the Facility and Under Its Supervision
70.3 - Inpatient Physical Therapy, Occupational Therapy, and
Speech
Pathology Services
o Ch 12 - Comprehensive Outpatient Rehabilitation Facility (CORF)
Coverage
10 - Comprehensive Outpatient Rehabilitation Facility (CORF) Services Provided by
Medicare
20 - Required and Optional CORF Services
20.1 - Required Services
20.2 - Optional CORF Services
30 - Rules for Provision of Services
30.1 - Rules for Payment of CORF Services
40 - Specific CORF Services
40.1 - Physicians’ Services
40.2 - Physical Therapy Services
40.3 - Occupational Therapy Services
40.4 – Speech Language Pathology Services
• Pub. 100-03 MEDICARE NATIONAL COVERAGE
DETERMINATIONS MANUAL
o Part 1
20.10 - Cardiac Rehabilitation Programs
30.1 - Biofeedback Therapy
30.1.1 - Biofeedback Therapy for the Treatment of Urinary
Incontinence
50.1 – Speech Generating Devices
50.2 - Electronic Speech Aids
50.4 - Tracheostomy Speaking Valve
o Part 2
150.2 - Osteogenic Stimulator
160.7 - Electrical Nerve Stimulators
160.12 - Neuromuscular Electrical Stimulation (NMES)
160.13 - Supplies Used in the Delivery of Transcutaneous
Electrical Nerve
Stimulation (TENS) and Neuromuscular Electrical Stimulation
(NMES)
160.17 - L-Dopa
o Part 3
170.1 - Institutional and Home Care Patient Education Programs
170.2 - Melodic Intonation Therapy
170.3 - Speech Pathology Services for the Treatment of Dysphagia
180 – Nutrition
o Part 4
230.8 - Non-implantable Pelvic Flood Electrical Stimulator
240.7 - Postural Drainage Procedures and Pulmonary Exercises
270.1 -Electrical Stimulation (ES) and Electromagnetic Therapy
for the
Treatment of Wounds
270.4 - Treatment of Decubitus Ulcers
280.3 - Mobility Assisted Equipment (MAE)
280.4 - Seat Lift
280.13 - Transcutaneous Electrical Nerve Stimulators (TENS)
290.1 - Home Health Visits to A Blind Diabetic
• Pub. 100-08 PROGRAM INTEGRITY MANUAL
o Chapter 3 - Verifying Potential Errors and Taking Corrective
Actions
3.4.1.1 - Linking LCD and NCD ID Numbers to Edits
o Chapter 13 - Local Coverage Determinations
13.5.1 - Reasonable and Necessary Provisions in LCDs
Specific policies may differ by setting. Other policies concerning therapy
services are found in other manuals. When a therapy service policy is specific
to a setting, it takes precedence over these general outpatient policies. For
special rules on:
• CORFs - See chapter 12 of this manual and also Pub. 100-
04, chapter 5;
• SNF - See chapter 8 of this manual and also Pub. 100-04,
chapter 6, for SNF claims/billing;
• HHA - See chapter 7 of this manual, and Pub. 100-04,
chapter 10;
• GROUP THERAPY AND STUDENTS - See Pub. 100-02,
chapter 15, §230;
• ARRANGEMENTS - Pub. 100-01, chapter 5, §10.3;
• COVERAGE is described in the Medicare Program
Integrity Manual, Pub. 100-08, chapter 13, §13.5.1; and
• THERAPY CAPS - See Pub. 100-04, chapter 5, §10.2, for
a complete description of this financial limitation.
C. General
Therapy services are a covered benefit in §§1861(g), 1861(p), and 1861(ll) of
the Act.
Therapy services may also be provided incident to the services of a
physician/NPP under §§1861(s)(2) and 1862(a)(20) of the Act.
Covered therapy services are furnished by providers, by others under
arrangements with and under the supervision of providers, or furnished by
suppliers (e.g., physicians, NPP, enrolled therapists), who meet the
requirements in Medicare manuals for therapy services.
Where a prospective payment system (PPS) applies, therapy services are paid
when services conform to the requirements of that PPS. Reimbursement for
therapy provided to Part A inpatients of hospitals or residents of SNFs in
covered stays is included in the respective PPS rates.
Payment for therapy provided by an HHA under a plan of treatment is
included in the home health PPS rate. Therapy may be billed by an HHA on
bill type 34x if there are no home health services billed under a home health
plan of care at the same time (e.g., the patient is not homebound), and there is
a valid therapy plan of treatment.
In addition to the requirements described in this chapter, the services must be
furnished in accordance with health and safety requirements set forth in
regulations at 42CFR484, and 42CFR485.
When therapy services may be furnished appropriately in a community pool
by a clinician in a physical therapist or occupational therapist private practice,
physician office, outpatient hospital, or outpatient SNF, the practice/office or
provider shall rent or lease the pool, or a specific portion of the pool. The use
of that part of the pool during specified times shall be restricted to the patients
of that practice or provider. The written agreement to rent or lease the pool
shall be available for review on request. When part of the pool is rented or
leased, the agreement shall describe the part of the pool that is used
exclusively by the patients of that practice/office or provider and the times
that exclusive use applies. Other providers, including rehabilitation agencies
(previously referred to as OPTs and ORFs) and CORFs, are subject to the
requirements outlined in the respective State Operations Manual regarding
rented or leased community pools.
220.1 - Conditions of Coverage and Payment for Outpatient Physical
Therapy, Occupational Therapy, or Speech-Language Pathology
Services
(Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19)
Reference: 42CFR424.24
Refer to §230.4 for physical therapist/occupational therapist in private practice rules.
Coverage rules for specific services are in Pub. 100-03, Medicare National Coverage
Determinations Manual.
Other payment rules are found in Pub. 100-04, Medicare Claims Processing Manual,
chapter 5.
Since the outpatient therapy benefit under Part B provides coverage only of therapy
services, payment can be made only for those services that constitute therapy. In cases
where there is doubt about whether a service is therapy, the contractor’s local coverage
determination (LCD) shall prevail.
In order for a service to be covered, it must have a benefit category in the statute, it must
not be excluded and it must be reasonable and necessary. Therapy services are a benefit
under §1861 of the Act. Consult Pub. 100-08, chapter 13, §13.5.1 for full descriptions of
a reasonable and necessary service.
Outpatient therapy services furnished to a beneficiary by a provider or supplier are
payable only when furnished in accordance with certain conditions. The following
conditions apply.
• Services are or were required because the individual needed therapy services (see
42CFR424.24(c),§220.1.3);
• A plan for furnishing such services has been established by a physician/NPP or by
the therapist providing such services and is periodically reviewed by a
physician/NPP* (see 42CFR424.24(c), §220.1.2);
• Services are or were furnished while the individual is or was under the care of a
physician* (see 42CFR424.24(c), §220.1.1);
• In certifying an outpatient plan of care for therapy a physician/NPP is
certifying that the above three conditions are met (42 CFR 424.24(c)).
Certification is required for coverage and payment of a therapy claim.
• Claims submitted for outpatient (and CORF) PT, OT, and SLP services must
contain the National Provider (NPI) of the certifying physician identified for a PT,
OT, and SLP plan of care. This requirement is effective for claims with dates of
service on or after October 1, 2012. (See Pub. 100-04, Medicare Claims
Processing Manual, chapter 5, section 10.3.)
• Claims submitted for outpatient (and CORF) PT, OT, and SLP services must
contain the required functional reporting. (See 42CFR410.59, 60, and 62), Pub.
100-04, Medicare Claims Processing Manual, chapter 5, section 10.6.) NOTE:
The applicable regulatory provisions were removed through the CY 2019 PFS
final rule, CMS-1693-F. Functional reporting requirements are no longer
applicable for claims for dates of service on and after January 1, 2019. See the
NOTE at the beginning of Section 220.4 for more information.
The patient functional limitations(s) reported on claims, as part of the functional
reporting, must be consistent with the functional limitations identified as part of the
therapy plan of care and expressed as part of the patient’s long term goals* (see
42CFR410.61, 42CFR410.105, Pub. 100-04, Medicare Claims Processing Manual,
chapter 5, section 10.6.) NOTE: The applicable regulatory provisions were removed
through the CY 2019 PFS final rule, CMS-1693-F. Functional reporting and its
documentation requirements are no longer applicable for claims or medical records
for dates of service on and after January 1, 2019.
220.1.1 - Care of a Physician/Nonphysician Practitioner (NPP)
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)
Although there is no Medicare requirement for an order, when documented in the medical
record, an order provides evidence that the patient both needs therapy services and is
under the care of a physician. The certification requirements are met when the physician
certifies the plan of care. If the signed order includes a plan of care (see essential
requirements of plan in §220.1.2), no further certification of the plan is required.
Payment is dependent on the certification of the plan of care rather than the order, but the
use of an order is prudent to determine that a physician is involved in care and available
to certify the plan.
(The CORF services benefit does not recognize an NPP for orders and certification.)
220.1.2 - Plans of Care for Outpatient Physical Therapy, Occupational
Therapy, or Speech-Language Pathology Services
(Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19)
Reference: 42CFR 410.61 and 410.105(c) (for CORFs)
A. Establishing the plan (See §220.1.3 for certifying the plan.)
The services must relate directly and specifically to a written treatment plan as described
in this chapter. The plan, (also known as a plan of care or plan of treatment) must be
established before treatment is begun. The plan is established when it is developed (e.g.,
written or dictated).
The signature and professional identity (e.g., MD, OTR/L) of the person who established
the plan, and the date it was established must be recorded with the plan. Establishing the
plan, which is described below, is not the same as certifying the plan, which is described
in §§220.1.1 and 220.1.3
Outpatient therapy services shall be furnished under a plan established by:
• A physician/NPP (consultation with the treating physical therapist,
occupational therapist, or speech-language pathologist is recommended.
Only a physician may establish a plan of care in a CORF;
• The physical therapist who will provide the physical therapy services;
• The occupational therapist who will provide the occupational therapy
services; or
• The speech-language pathologist who will provide the speech-language
pathology services.
The plan may be entered into the patient’s therapy record either by the person who
established the plan or by the provider’s or supplier’s staff when they make a written
record of that person’s oral orders before treatment is begun.
Treatment under a Plan. The evaluation and treatment may occur and are both billable
either on the same day or at subsequent visits. It is appropriate that treatment begins
when a plan is established.
Therapy may be initiated by qualified professionals or qualified personnel based on a
dictated plan. Treatment may begin before the plan is committed to writing only if the
treatment is performed or supervised by the same clinician who establishes the plan.
Payment for services provided before a plan is established may be denied.
Two Plans. It is acceptable to treat under two separate plans of care when different
physician’s/NPP’s refer a patient for different conditions. It is also acceptable to
combine the plans of care into one plan covering both conditions if one or the other
referring physician/NPP is willing to certify the plan for both conditions. The treatment
notes continue to require timed code treatment minutes and total treatment time and need
not be separated by plan. Progress reports should be combined if it is possible to make
clear that the goals for each plan are addressed. Separate progress reports referencing
each plan of care may also be written, at the discretion of the treating clinician, or at the
request of the certifying physician/NPP, but shall not be required by contractors.
B. Contents of Plan (See §220.1.3 for certifying the plan.)
The plan of care shall contain, at minimum, the following information as required by
regulation (42CFR424.24, 410.61, and 410.105(c) (for CORFs)). (See §220.3 for further
documentation requirements):
• Diagnoses;
• Long term treatment goals; and
• Type, amount, duration and frequency of therapy services.
The plan of care shall be consistent with the related evaluation, which may be attached
and is considered incorporated into the plan. The plan should strive to provide treatment
in the most efficient and effective manner, balancing the best achievable outcome with
the appropriate resources.
Long term treatment goals should be developed for the entire episode of care in the
current setting. When the episode is anticipated to be long enough to require more than
one certification, the long term goals may be specific to the part of the episode that is
being certified. Goals should be measurable and pertain to identified functional
impairments. Therapists typically also establish short term goals, such as goals for a
week or month of therapy, to help track progress toward the goal for the episode of care.
If the expected episode of care is short, for example therapy is expected to be completed
in 4 to 6 treatment days, the long term and short term goals may be the same. In other
instances measurable goals may not be achievable, such as when treatment in a particular
setting is unexpectedly cut short (such as when care is transferred to another therapy
provider) or when the beneficiary suffers an exacerbation of his/her existing condition
terminating the current episode; documentation should state the clinical reasons progress
cannot be shown. The functional impairments identified and expressed in the long term
treatment goals must be consistent with those used in the claims-based functional
reporting, using nonpayable G-codes and severity modifiers, for services furnished on or
after January 1, 2013. (Reference: 42CFR410.61 and 42CFR410.105 (for CORFs).
NOTE: The regulatory requirements at 42CFR410.61 and 42CFR410.105 (for CORFs)
for the plan of care’s long-term goals to be consistent with functional impairments
identified for purposes of functional reporting, were removed by the CY 2019 Physician
Fee Schedule final rule, CMS-1693-F. Functional reporting and its associated
documentation requirements are no longer applicable for claims or medical records for
dates of service on and after January 1, 2019. See the NOTE at the beginning of Section
220.4 for more information.
The type of treatment may be PT, OT, or SLP, or, where appropriate, the type may be a
description of a specific treatment or intervention. (For example, where there is a single
evaluation service, but the type is not specified, the type is assumed to be consistent with
the therapy discipline (PT, OT, SLP) ordered, or of the therapist who provided the
evaluation.) Where a physician/NPP establishes a plan, the plan must specify the type
(PT, OT, SLP) of therapy planned.
There shall be different plans of care for each type of therapy discipline. When more
than one discipline is treating a patient, each must establish a diagnosis, goals, etc.
independently. However, the form of the plan and the number of plans incorporated into
one document are not limited as long as the required information is present and related to
each discipline separately. For example, a physical therapist may not provide services
under an occupational therapist plan of care. However, both may be treating the patient
for the same condition at different times in the same day for goals consistent with their
own scope of practice.
The amount of treatment refers to the number of times in a day the type of treatment will
be provided. Where amount is not specified, one treatment session a day is assumed.
The frequency refers to the number of times in a week the type of treatment is provided.
Where frequency is not specified, one treatment is assumed. If a scheduled holiday
occurs on a treatment day that is part of the plan, it is appropriate to omit that treatment
day unless the clinician who is responsible for writing progress reports determines that a
brief, temporary pause in the delivery of therapy services would adversely affect the
patient’s condition.
The duration is the number of weeks, or the number of treatment sessions, for THIS
PLAN of care. If the episode of care is anticipated to extend beyond the 90 calendar day
limit for certification of a plan, it is desirable, although not required, that the clinician
also estimate the duration of the entire episode of care in this setting.
The frequency or duration of the treatment may not be used alone to determine medical
necessity, but they should be considered with other factors such as condition, progress,
and treatment type to provide the most effective and efficient means to achieve the
patients’ goals. For example, it may be clinically appropriate, medically necessary, most
efficient and effective to provide short term intensive treatment or longer term and less
frequent treatment depending on the individuals’ needs.
It may be appropriate for therapists to taper the frequency of visits as the patient
progresses toward an independent or caregiver assisted self-management program with
the intent of improving outcomes and limiting treatment time. For example, treatment
may be provided 3 times a week for 2 weeks, then 2 times a week for the next 2 weeks,
then once a week for the last 2 weeks. Depending on the individual’s condition, such
treatment may result in better outcomes, or may result in earlier discharge than routine
treatment 3 times a week for 4 weeks. When tapered frequency is planned, the exact
number of treatments per frequency level is not required to be projected in the plan,
because the changes should be made based on assessment of daily progress. Instead, the
beginning and end frequencies shall be planned. For example, amount, frequency and
duration may be documented as “once daily, 3 times a week tapered to once a week over
6 weeks”. Changes to the frequency may be made based on the clinicians clinical
judgment and do not require recertification of the plan unless requested by the
physician/NPP. The clinician should consider any comorbidities, tissue healing, the
ability of the patient and/or caregiver to do more independent self-management as
treatment progresses, and any other factors related to frequency and duration of
treatment.
The above policy describes the minimum requirements for payment. It is anticipated that
clinicians may choose to make their plans more specific, in accordance with good
practice. For example, they may include these optional elements: short term goals, goals
and duration for the current episode of care, specific treatment interventions, procedures,
modalities or techniques and the amount of each. Also, notations in the medical record of
beginning date for the plan are recommended but not required to assist Medicare
contractors in determining the dates of services for which the plan was effective.
C. Changes to the Therapy Plan
Changes are made in writing in the patient’s record and signed by one of the following
professionals responsible for the patient’s care:
• The physician/NPP;
• The physical therapist (in the case of physical therapy);
• The speech-language pathologist (in the case of speech-language pathology
services);
• The occupational therapist (in the case of occupational therapy services); or
• The registered professional nurse or physician/NPP on the staff of the facility
pursuant to the oral orders of the physician/NPP or therapist.
While the physician/NPP may change a plan of treatment established by the therapist
providing such services, the therapist may not significantly alter a plan of treatment
established or certified by a physician/NPP without their documented written or verbal
approval (see §220.1.3(C)). A change in long-term goals, (for example if a new
condition was to be treated) would be a significant change. Physician/NPP certification
of the significantly modified plan of care shall be obtained within 30 days of the initial
therapy treatment under the revised plan. An insignificant alteration in the plan would be
a change in the frequency or duration due to the patient’s illness, or a modification of
short-term goals to adjust for improvements made toward the same long-term goals. If a
patient has achieved a goal and/or has had no response to a treatment that is part of the
plan, the therapist may delete a specific intervention from the plan of care prior to
physician/ NPP approval. This shall be reported to the physician/NPP responsible for the
patient’s treatment prior to the next certification.
Procedures (e.g., neuromuscular reeducation) and modalities (e.g., ultrasound) are not
goals, but are the means by which long and short term goals are obtained. Changes to
procedures and modalities do not require physician signature when they represent
adjustments to the plan that result from a normal progression in the patient’s disease or
condition or adjustments to the plan due to lack of expected response to the planned
intervention, when the goals remain unchanged. Only when the patient’s condition
changes significantly, making revision of long term goals necessary, is a
physician’s/NPP’s signature required on the change, (long term goal changes may be
accompanied by changes to procedures and modalities).
220.1.3 - Certification and Recertification of Need for Treatment and
Therapy Plans of Care
(Rev. 88, Issued: 05-07-08, Effective: 01-01-08, Implementation: 06-09-08)
Reference: 42CFR424.24(c)
See specific certification rules in Pub. 100-01, chapter 4, §20 for hospital services.
A. Method and Disposition of Certifications
Certification requires a dated signature on the plan of care or some other document that
indicates approval of the plan of care. It is not appropriate for a physician/NPP to certify
a plan of care if the patient was not under the care of some physician/NPP at the time of
the treatment or if the patient did not need the treatment. Since delayed certification is
allowed, the date the certification is signed is important only to determine if it is timely or
delayed. The certification must relate to treatment during the interval on the claim.
Unless there is reason to believe the plan was not signed appropriately, or it is not timely,
no further evidence that the patient was under the care of a physician/NPP and that the
patient needed the care is required.
The format of all certifications and recertifications and the method by which they are
obtained is determined by the individual facility and/or practitioner. Acceptable
documentation of certification may be, for example, a physician’s progress note, a
physician/NPP order, or a plan of care that is signed and dated by a physician/NPP, and
indicates the physician/NPP is aware that therapy service is or was in progress and the
physician/NPP makes no record of disagreement with the plan when there is evidence the
plan was sent (e.g., to the office) or is available in the record (e.g., of the institution that
employs the physician/NPP) for the physician/NPP to review. For example, if during the
course of treatment under a certified plan of care a physician sends an order for continued
treatment for 2 more weeks, contractors shall accept the order as certification of
continued treatment for 2 weeks under the same plan of care. If the new certification is
for less treatment than previously planned and certified, this new certification takes the
place of any previous certification. At the end of the 2 weeks of treatment (which might
extend more than 2 calendar weeks from the date the order/certification was signed)
another certification would be required if further treatment was documented as medically
necessary.
The certification should be retained in the clinical record and available if requested by the
contractor.
B. Initial Certification of Plan
The physician’s/NPP’s certification of the plan (with or without an order) satisfies all of
the certification requirements noted above in §220.1 for the duration of the plan of care,
or 90 calendar days from the date of the initial treatment, whichever is less. The initial
treatment includes the evaluation that resulted in the plan.
Timing of Initial Certification. The provider or supplier (e.g., facility, physician/NPP, or
therapist) should obtain certification as soon as possible after the plan of care is
established, unless the requirements of delayed certification are met. “As soon as
possible” means that the physician/NPP shall certify the initial plan as soon as it is
obtained, or within 30 days of the initial therapy treatment. Since payment may be
denied if a physician does not certify the plan, the therapist should forward the plan to the
physician as soon as it is established. Evidence of diligence in providing the plan to the
physician may be considered by the Medicare contractor during review in the event of a
delayed certification.
Timely certification of the initial plan is met when physician/NPP certification of the plan
is documented, by signature or verbal order, and dated in the 30 days following the first
day of treatment (including evaluation). If the order to certify is verbal, it must be
followed within 14 days by a signature to be timely. A dated notation of the order to
certify the plan should be made in the patient’s medical record.
Recertification is not required if the duration of the initially certified plan of care is more
than the duration (length) of the entire episode of treatment.
C. Review of Plan and Recertification
Reference: 42CFR424.24(c), 1861(r), 42CFR 410.61(e).
The timing of recertification changed on January 1, 2008. Certifications signed on or
after January 1, 2008, follow the rules in this section. Certifications signed on or prior to
December 31, 2007, follow the rule in effect at that time, which required recertification
every 30 calendar days.
Payment and coverage conditions require that the plan must be reviewed, as often as
necessary but at least whenever it is certified or recertified to complete the certification
requirements. It is not required that the same physician/NPP who participated initially in
recommending or planning the patient’s care certify and/or recertify the plans.
Recertifications that document the need for continued or modified therapy should be
signed whenever the need for a significant modification of the plan becomes evident, or
at least every 90 days after initiation of treatment under that plan, unless they are delayed.
Physician/NPP Options for Certification. A physician/NPP may certify or recertify a
plan for whatever duration of treatment the physician/NPP determines is appropriate, up
to a maximum of 90 calendar days. Many episodes of therapy treatment last less than 30
calendar days. Therefore, it is expected that the physician/NPP should certify a plan that
appropriately estimates the duration of care for the individual, even if it is less than 90
days. If the therapist writes a plan of care for a duration that is more or less than the
duration approved by the physician/NPP, then the physician/NPP would document a
change to the duration of the plan and certify it for the duration the physician/NPP finds
appropriate (up to 90 days). Treatment beyond the duration certified by the
physician/NPP requires that a plan be recertified for the extended duration of treatment.
It is possible that patients will be discharged by the therapist before the end of the
estimated treatment duration because some will improve faster than estimated and/or
some were successfully progressed to an independent home program.
Physicians/NPPs may require that the patient make a physician/NPP visit for an
examination if, in the professional’s judgment, the visit is needed prior to certifying the
plan, or during the planned treatment. Physicians/NPPs should indicate their requirement
for visits, preferably on an order preceding the treatment, or on the plan of care that is
certified. If the physician wishes to restrict the patient’s treatment beyond a certain date
when a visit is required, the physician should certify a plan only until the date of the visit.
After that date, services will not be considered reasonable and necessary due to lack of a
certified plan. Physicians/NPPs should not sign a certification if they require a visit and a
visit was not made. However, Medicare does not require a visit unless the National
Coverage Determination (NCD) for a particular treatment requires it (e.g., see Pub. 100-
03, §270.1 - Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment
of Wounds).
Restrictions on Certification. Certifications and recertifications by doctors of podiatric
medicine must be consistent with the scope of the professional services provided by a
doctor of podiatric medicine as authorized by applicable state law. Optometrists may
order and certify only low vision services. Chiropractors may not certify or recertify
plans of care for therapy services.
D. Delayed Certification
References: §1835(a) of the Act
42CFR424.11(d)(3)
Certifications are required for each interval of treatment based on the patient’s needs, not
to exceed 90 calendar days from the initial therapy treatment. Certifications are timely
when the initial certification (or certification of a significantly modified plan of care) is
dated within 30 calendar days of the initial treatment under that plan. Recertification is
timely when dated during the duration of the initial plan of care or within 90 calendar
days of the initial treatment under that plan, whichever is less. Delayed certification and
recertification requirements shall be deemed satisfied where, at any later date, a
physician/NPP makes a certification accompanied by a reason for the delay.
Certifications are acceptable without justification for 30 days after they are due. Delayed
certification should include one or more certifications or recertifications on a single
signed and dated document.
Delayed certifications should include any evidence the provider or supplier considers
necessary to justify the delay. For example, a certification may be delayed because the
physician did not sign it, or the original was lost. In the case of a long delayed
certification (over 6 months), the provider or supplier may choose to submit with the
delayed certification some other documentation (e.g., an order, progress notes, telephone
contact, requests for certification or signed statement of a physician/NPP) indicating need
for care and that the patient was under the care of a physician at the time of the treatment.
Such documentation may be requested by the contractor for delayed certifications if it is
required for review.
It is not intended that needed therapy be stopped or denied when certification is delayed.
The delayed certification of otherwise covered services should be accepted unless the
contractor has reason to believe that there was no physician involved in the patient’s care,
or treatment did not meet the patient’s need (and therefore, the certification was signed
inappropriately).
EXAMPLE: Payment should be denied if there is a certification signed 2 years after
treatment by a physician/NPP who has/had no knowledge of the patient when the medical
record also shows e.g., no order, note, physician/NPP attended meeting, correspondence
with a physician/NPP, documentation of discussion of the plan with a physician/NPP,
documentation of sending the plan to any physician/NPP, or other indication that there
was a physician/NPP involved in the case.
EXAMPLE: Payment should not be denied, even when certified 2 years after treatment,
when there is evidence that a physician approved needed treatment, such as an order,
documentation of therapist/physician/NPP discussion of the plan, chart notes, meeting
notes, requests for certification, certifications for intervals before or after the service in
question, or physician/NPP services during which the medical record or the patient’s
history would, in good practice, be reviewed and would indicate therapy treatment is in
progress.
EXAMPLE: Subsequent certifications of plans for continued treatment for the same
condition in the same patient may indicate physician certification of treatment that
occurred between certification dates, even if the signature for one of the plans in the
episode is delayed. If a certified plan of care ends March 30
th
and a new plan of care for
continued treatment after March 30
th
is developed or signed by a therapist on April 15
th
and that plan is subsequently certified, that certification may be considered delayed and
acceptable effective from the first treatment date after March 30
th
for the frequency and
duration as described in the plan. Of course, documentation should continue to indicate
that therapy during the delay is medically necessary, as it would for any treatment. The
certification of the physician/NPP is interpreted as involvement and approval of the
ongoing episode of treatment, including the treatment that preceded the date of the
certification unless the physician/NPP indicates otherwise.
E. Denials Due to Certification
Denial for payment that is based on absence of certification is a technical denial, which
means a statutory requirement has not been met. Certification is a statutory requirement
in SSA 1835(a)(2)- (‘periodic review” of the plan).
For example, if a patient is treated and the provider/supplier cannot produce (on
contractor request) a plan of care (timely or delayed) for the billed treatment dates
certified by a physician/NPP, then that service might be denied for lack of the required
certification. If an appropriate certification is later produced, the denial shall be
overturned.
In the case of a service furnished under a provider agreement as described in
42CFR489.21, the provider is precluded from charging the beneficiary for services
denied as a result of missing certification.
However, if the service is provided by a supplier (in the office of the physician/NPP, or
therapist) a technical denial due to absence of a certification results in beneficiary
liability. For that reason, it is recommended that the patient be made aware of the need
for certification and the consequences of its absence.
A technical denial decision may be reopened by the contractor or reversed on appeal as
appropriate, if delayed certification is later produced.
220.1.4 - Requirement That Services Be Furnished on an Outpatient
Basis
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)
Reference: 42CFR410.60
Therapy services are payable under the Physician Fee Schedule when furnished by 1.) a
provider to its outpatients in the patient’s home; 2.) a provider to patients who come to
the facility’s outpatient department; 3.) a provider to inpatients of other institutions, or
4.) a supplier to patients in the office or in the patient’s home. (CORF rules differ on
providing therapy at home.)
Coverage includes therapy services furnished by participating hospitals and SNFs to their
inpatients who have exhausted Part A inpatient benefits or who are otherwise not eligible
for Part A benefits. Providers of therapy services that have inpatient facilities, other than
participating hospitals and SNFs, may not furnish covered therapy services to their own
inpatients. However, since the inpatients of one institution may be considered the
outpatients of another institution, all providers of therapy services may furnish such
services to inpatients of another health facility.
A certified distinct part of an institution is considered to be a separate institution from a
nonparticipating part of the institution. Consequently, the certified distinct part may
render covered therapy services to the inpatients of the noncertified part of the institution
or to outpatients. The certified part must bill the A/B MAC (A) under Part B.
Therapy services are payable when furnished in the home at the same physician fee
schedule payment rates as in other outpatient settings. Additional expenses incurred by
providers of outpatient therapy due to travel to the beneficiary are not covered.
Under the Medicare law, there is no authority to require a provider to furnish a type of
service. Therefore, a hospital or SNF may furnish therapy to its inpatients without having
to set up facilities and procedures for furnishing those services to its outpatients.
However, if the provider chooses to furnish a particular service, it may not charge any
individual or other person for items or services for which the individual is entitled to have
payment made under the program because it is bound by its agreement with Medicare.
Thus, whenever a hospital or SNF furnishes outpatient therapy to a Medicare beneficiary
(either directly or under arrangements with others) it must bill the program under Part B
and may charge the patient only for the applicable deductible and coinsurance.
220.2 - Reasonable and Necessary Outpatient Rehabilitation Therapy
Services
(Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19)
References: Pub. 100-08, chapter 13, §13.5.1,
42CFR410.59,
42CFR410.60
A. General
To be covered, services must be skilled therapy services as described in this chapter and
be rendered under the conditions specified. Services provided by professionals or
personnel who do not meet the qualification standards, and services by qualified people
that are not appropriate to the setting or conditions are unskilled services. A service is
not considered a skilled therapy service merely because it is furnished by a therapist or by
a therapist/therapy assistant under the direct or general supervision, as applicable, of a
therapist. If a service can be self-administered or safely and effectively furnished by an
unskilled person, without the direct or general supervision, as applicable, of a therapist,
the service cannot be regarded as a skilled therapy service even though a therapist
actually furnishes the service. Similarly, the unavailability of a competent person to
provide a non-skilled service, notwithstanding the importance of the service to the
patient, does not make it a skilled service when a therapist furnishes the service.
Skilled therapy services may be necessary to improve a patient’s current condition, to
maintain the patient’s current condition, or to prevent or slow further deterioration of the
patient’s condition. For further information see 220.2, subsections C (Rehabilitative
Services) and subsection D (Maintenance Programs).
Services that do not meet the requirements for covered therapy services in Medicare
manuals are not payable using codes and descriptions as therapy services. For example,
services related to activities for the general good and welfare of patients, e.g., general
exercises to promote overall fitness and flexibility and activities to provide diversion or
general motivation, do not constitute therapy services for Medicare purposes. Also,
services not provided under a therapy plan of care, or provided by staff who are not
qualified or appropriately supervised, are not payable therapy services.
Examples of coverage policies that apply to all outpatient therapy claims are in this
chapter, in Pub. 100-04, chapter 5, and Pub. 100-08, chapter 13. Some policies in other
manuals are repeated here for emphasis and clarification. Further details on documenting
reasonable and necessary services are found in section 220.3 of this chapter.
B. Reasonable and Necessary
To be considered reasonable and necessary, each of the following conditions must be
met. (This is a representative list of required conditions and does not fully describe
reasonable and necessary services. See the remainder of this section and associated
information in section 230.)
• The services shall be considered under accepted standards of medical practice to
be a specific and effective treatment for the patient’s condition. Acceptable
practices for therapy services are found in:
o Medicare manuals (such as this manual and Publications 100-03 and 100-04),
o Contractors Local Coverage Determinations (LCDs and NCDs are available
on the Medicare Coverage Database: http://www.cms.hhs.gov/mcd, and
o Guidelines and literature of the professions of physical therapy, occupational
therapy and speech-language pathology.
• The services shall be of such a level of complexity and sophistication or the
condition of the patient shall be such that the services required can be safely
and effectively performed only by a therapist, or in the case of physical
therapy and occupational therapy by or under the supervision of a therapist.
Services that do not require the performance or supervision of a therapist are
not skilled and are not considered reasonable or necessary therapy services,
even if they are performed or supervised by a qualified professional.
Medicare coverage does not turn on the presence or absence of a beneficiary’s
potential for improvement from the therapy, but rather on the beneficiary’s
need for skilled care. (For additional guidance, see subsection D below
related to Maintenance Programs.)
• If the contractor determines the services furnished were of a type that could
have been safely and effectively performed only by or under the supervision
of such a qualified professional, the contractor shall presume that such
services were properly supervised when required. However, this presumption
is rebuttable and, if in the course of processing a claim, the contractor finds
that services were not furnished under proper supervision, it shall deny the
claim and bring this matter to the attention of the Division of Survey and
Certification of the Regional Office.
• While a beneficiary’s particular medical condition is a valid factor in deciding
if skilled therapy services are needed, a beneficiary’s diagnosis or prognosis
cannot be the sole factor in deciding that a service is or is not skilled. The key
issue is whether the skills of a therapist are needed to treat the illness or
injury, or whether the services can be carried out by nonskilled personnel. See
items C and D for descriptions of covered skilled services; and
• The amount, frequency, and duration of the services must be reasonable under
accepted standards of practice. The contractor shall consult local
professionals or the state or national therapy associations in the development
of any utilization guidelines.
NOTE: Claims for therapy services denied because they are not considered reasonable
and necessary under §1862(a)(1)(A) of the Act and, for services furnished on or after
January 1, 2013, those denied as a result of application of the therapy caps under
§1833(g)(1) or (g)(3) are subject to consideration under the waiver of liability provision
in §1879 of the Act. Although Section 50202 of the Bipartisan Budget Act (BBA) of
2018 repealed the therapy caps and its exceptions process effective January 1, 2018, it did
not change provider liability procedures which first became effective January 1, 2013.
Section 1833(g)(8) of the Social Security Act (as redesignated by the BBA of 2018)
continues to provide limitation of liability (LOL) protections to beneficiaries receiving
outpatient therapy services on or after January 1, 2013, when services are denied for
certain reasons, including failure to include a necessary −KX modifier. (Section 1879
provides LOL protections for reasonable and necessary denials more generally.) Under
section §1833(g)(8), the therapist or therapy provider is financially liable for the cost of
therapy services provided to a beneficiary above the threshold amount when Medicare
denies payment for failure to use the −KX modifier to indicate that the services are
medically necessary as justified by documentation in the medical record. In order for the
therapist or therapy provider to transfer liability to the beneficiary, s/he must issue a valid
ABN, Form CMS-R-131. For more information, see the Therapy Services webpage at:
https://www.cms.gov/Medicare/Billing/TherapyServices/index.html for the Advance
Beneficiary Notice of Noncoverage (ABN) Frequently Asked Questions (FAQ)
document that was posted to reflect the changes of the Bipartisan Budget Act of 2018.
Please find the document titled: “August 2018 ABN FAQs” in the Downloads section on
this webpage.
C. Rehabilitative Therapy
Rehabilitative therapy includes services designed to address recovery or improvement in
function and, when possible, restoration to a previous level of health and well-being.
Therefore, evaluation, re-evaluation and assessment documented in the Progress Report
should describe objective measurements which, when compared, show improvements in
function, decrease in severity or rationalization for an optimistic outlook to justify
continued treatment. Improvement is evidenced by successive objective measurements
whenever possible (see objective measurement and other instruments for evaluation in
the §220.3.C of this chapter). If an individual’s expected rehabilitation potential is
insignificant in relation to the extent and duration of therapy services required to achieve
such potential, rehabilitative therapy is not reasonable and necessary.
Rehabilitative therapy services are skilled procedures that may include but are not limited
to:
• Evaluations and reevaluations;
• Establishment of treatment goals specific to the patient’s disability or
dysfunction and designed to specifically address each problem identified in
the evaluation;
• Design of a plan of care addressing the patient’s disorder, including
establishment of procedures to obtain goals, determining the frequency and
intensity of treatment;
• Continued assessment and analysis during implementation of the services at
regular intervals;
• Instruction leading to establishment of compensatory skills;
• Selection of devices to replace or augment a function (e.g., for use as an
alternative communication system and short-term training on use of the device
or system); and
• Training of patient and family to augment rehabilitative treatment. Training
of staff and family should be ongoing throughout treatment and instructions
modified intermittently as the patient’s status changes.
Rehabilitative therapy requires the skills of a therapist to safely and effectively furnish a
recognized therapy service whose goal is improvement of an impairment or functional
limitation. (See definition of therapist in section 220.A of this chapter.) Services that can
be safely and effectively furnished by nonskilled personnel or by PTAs or OTAs without
the supervision of therapists are not rehabilitative therapy services.
Rehabilitative therapy may be needed, and improvement in a patient’s condition may
occur, even when a chronic, progressive, degenerative, or terminal condition exists. For
example, a terminally ill patient may begin to exhibit self-care, mobility, and/or safety
dependence requiring skilled therapy services. The fact that full or partial recovery is not
possible does not necessarily mean that skilled therapy is not needed to improve the
patient’s condition or to maximize his/her functional abilities. The deciding factors are
always whether the services are considered reasonable, effective treatments for the
patient’s condition and require the skills of a therapist, or whether they can be safely and
effectively carried out by nonskilled personnel.
Rehabilitative therapy is not required to effect improvement or restoration of function
when a patient suffers a transient and easily reversible loss or reduction of function (e.g.,
temporary and generalized weakness, which may follow a brief period of bed rest
following surgery) that could reasonably be expected to improve spontaneously as the
patient gradually resumes normal activities. Therapy furnished in such situations is not
considered reasonable and necessary for the treatment of the individual’s illness or injury
and the services are not covered.
If at any point in the treatment of an illness it is determined that the treatment is not
rehabilitative, the services will no longer be considered reasonable and necessary under
this section. (See Section 220.2 D for additional covered therapy benefits under
maintenance programs). Services that are not reasonable or necessary are excluded from
coverage under §1862(a)(1)(A) of the Act.
D. Maintenance Programs
Skilled therapy services that do not meet the criteria for rehabilitative therapy may be
covered in certain circumstances as maintenance therapy under a maintenance program.
The goals of a maintenance program would be, for example, to maintain functional status
or to prevent or slow further deterioration in function.
Coverage for skilled therapy services related to a reasonable and necessary maintenance
program is available in the following circumstances:
• Establishment or design of maintenance programs. If the specialized skill,
knowledge and judgment of a qualified therapist are required to establish or
design a maintenance program to maintain the patient’s current condition or to
prevent or slow further deterioration, the establishment or design of a
maintenance program by a qualified therapist is covered. If skilled therapy
services by a qualified therapist are needed to instruct the patient or appropriate
caregiver regarding the maintenance program, such instruction is covered. If
skilled therapy services are needed for periodic reevaluations or reassessments of
the maintenance program, such periodic reevaluations or reassessments are
covered.
• Delivery of maintenance programs. Once a maintenance program is
established, coverage of therapy services to carry out a maintenance program
turns on the beneficiary’s need for skilled care. A maintenance program can
generally be performed by the beneficiary alone or with the assistance of a family
member, caregiver or unskilled personnel. In such situations, coverage is not
provided. However, skilled therapy services are covered when an individualized
assessment of the patient’s clinical condition demonstrates that the specialized
judgment, knowledge, and skills of a qualified therapist are necessary for the
performance of safe and effective services in a maintenance program. Such
skilled care is necessary for the performance of a safe and effective maintenance
program only when (a) the therapy procedures required to maintain the patient’s
current function or to prevent or slow further deterioration are of such complexity
and sophistication that the skills of a qualified therapist are required to furnish the
therapy procedure or (b) the particular patient’s special medical complications
require the skills of a qualified therapist to furnish a therapy service required to
maintain the patient’s current function or to prevent or slow further deterioration,
even if the skills of a therapist are not ordinarily needed to perform such therapy
procedures. Unlike coverage for rehabilitation therapy, coverage of therapy
services to carry out a maintenance program does not depend on the presence or
absence of the patient’s potential for improvement from the therapy.
The deciding factors are always whether the services are considered reasonable, effective
treatments for the patient’s condition and require the skills of a therapist, or whether they
can be safely and effectively carried out by nonskilled personnel or caregivers.
The examples that follow are intended to provide illustrations of how coverage
determinations are made. These examples are not intended to include all possible
situations in which coverage is provided or all reasons for denying coverage. Rather they
are intended only to show how to analyze the coverage issue.
Example #1 reflects a typical outpatient scenario in which a patient has been receiving
ongoing therapy under a physical therapy plan of care and the physical therapist begins
the establishment of the maintenance program prior to the patient’s anticipated discharge
date.
EXAMPLE: A patient with Parkinson’s disease is nearing the end of a rehabilitative
physical therapy program and requires the services of a therapist during the last week(s)
of treatment to determine what type of exercises will contribute the most to maintain
function or to prevent or slow further deterioration of the patient’s present functional
level following cessation of treatment. In such situations, the establishment of a
maintenance program appropriate to the capacity and tolerance of the patient by the
qualified therapist, the instruction of the patient or family members in carrying out the
program, and such reassessments and/or reevaluations as may be required may constitute
covered therapy because of the need for the skills of a qualified therapist.
Example #2 is an outpatient scenario in which a patient who has not been receiving
ongoing therapy under a therapy plan of care needs a maintenance plan.
EXAMPLE: A patient with multiple sclerosis needs a maintenance program to slow or
prevent deterioration in communication ability caused by the medical condition. Therapy
services from a qualified speech-language pathologist may be covered to establish a
maintenance program even though the patient’s current medical condition does not yet
justify the need for individual skilled therapy sessions. Evaluation, establishment of the
program, and training the family or support personnel may require the skills of a therapist
and would be covered. NOTE: In this example, the skills of a therapist are not required
to actually carry out the maintenance program services and, as a result, are not covered.
Example #3 describes a scenario where the skilled services of a therapist would be
necessary to actually carry out the maintenance program services.
EXAMPLE: Where there is an unhealed, unstable fracture that requires regular
exercise to maintain function until the fracture heals, the skills of a therapist may
be needed to ensure that the fractured extremity is maintained in proper position
and alignment during range of motion exercises. In this case, since the skills of a
therapist may be required to safely carry out the maintenance program given this
particular patient’s special medical complications, therapy services would be
covered.
Example #4 describes another scenario where the skilled services of a therapist are needed
to actually carry out the maintenance program services.
EXAMPLE: A patient with a long history of Multiple Sclerosis has difficulties
transferring in and out of the wheelchair and maintaining range of motion (ROM)
of the lower extremities (LEs) due to increased spasticity muscle tone since the
most recent exacerbation episode of her Multiple Sclerosis. The beneficiary is
unable to walk but is independent with the use of her wheelchair. The beneficiary
needs to be able to safely transfer in and out of her wheelchair by herself or with
the assistance of a family member or other caregiver(s). After an individualized
assessment by the physical therapist, and given the patient’s overall medical and
physical condition, the skills of the physical therapist are required to instruct the
patient and/or caregivers in proper techniques of wheelchair transfers and LE
stretches due to the special medical complications from the progression of
Multiple Sclerosis. When the physical therapist determines that the patient can
carry out the transfers and stretching activities safely and effectively, either alone
or with the assistance of the caregivers, the skills of the physical therapist are no
longer necessary to furnish the maintenance therapy; and, the patient is discharged
from PT.
Example #5 describes a scenario where a patient on a maintenance program needs
intermittent review and possibly a new or revised maintenance program.
EXAMPLE: A patient who has a progressive degenerative disease is performing
the activities in a maintenance program established by a therapist with the
assistance of family members. The program needs to be re-evaluated to
determine whether assistive equipment is needed and to establish a new or revised
maintenance program to maintain function or to prevent or slow further
deterioration. Intermittent re-evaluation of the maintenance program would
generally be covered as this is a service that requires the skills of a therapist.
Should the therapist conducting the re-evaluation determine that the program
needs to be revised, these services would generally be covered.
Maintenance program services that do not meet the criteria of this section are not
reasonable or necessary and are not covered under §1862(a)(1)(A) of the Act.
The maintenance program provisions outlined in this section do not apply to the PT, OT,
or SLP services furnished in a comprehensive outpatient rehabilitation facility (CORF)
because the statute specifies that CORF services are rehabilitative.
220.3 - Documentation Requirements for Therapy Services
(Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19)
A. General
To be payable, the medical record and the information on the claim form must
consistently and accurately report covered therapy services, as documented in the medical
record. Documentation must be legible, relevant and sufficient to justify the services
billed. In general, services must be covered therapy services provided according to
Medicare requirements. Medicare requires that the services billed be supported by
documentation that justifies payment. Documentation must comply with all requirements
applicable to Medicare claims.
The documentation guidelines in sections 220 and 230 of this chapter identify the
minimal expectations of documentation by providers or suppliers or beneficiaries
submitting claims for payment of therapy services to the Medicare program. State or
local laws and policies, or the policies or professional guidelines of the relevant
profession, the practice, or the facility may be more stringent. It is encouraged but not
required that narratives that specifically justify the medical necessity of services be
included in order to support approval when those services are reviewed. (See also section
220.2 - Reasonable and Necessary Outpatient Rehabilitation Therapy Services)
Contractors shall consider the entire record when reviewing claims for medical necessity
so that the absence of an individual item of documentation does not negate the medical
necessity of a service when the documentation as a whole indicates the service is
necessary. Services are medically necessary if the documentation indicates they meet the
requirements for medical necessity including that they are skilled, rehabilitative services,
provided by clinicians (or qualified professionals when appropriate) with the approval of
a physician/NPP, safe, and effective (i.e., progress indicates that the care is effective in
rehabilitation of function).
B. Documentation Required
List of required documentation. These types of documentation of therapy services are
expected to be submitted in response to any requests for documentation, unless the
contractor requests otherwise. The timelines are minimum requirements for Medicare
payment. Document as often as the clinician’s judgment dictates but no less than the
frequency required in Medicare policy:
• Evaluation and Plan of Care (may be one or two documents). Include the initial
evaluation and any re-evaluations relevant to the episode being reviewed;
• Certification (physician/NPP approval of the plan) and recertifications when
records are requested after the certification/recertification is due. See definitions in
section 220 and certification policy in section 220.1.3 of this chapter. Certification (and
recertification of the plan when applicable) are required for payment and must be
submitted when records are requested after the certification or recertification is due.
• Progress Reports (including Discharge Notes, if applicable) when records are
requested after the reports are due. (See definitions in section 220 and descriptions in
220.3 D);
• Treatment notes for each treatment day (may also serve as progress reports when
required information is included in the notes);
• A separate justification statement may be included either as a separate document
or within the other documents if the provider/supplier wishes to assure the contractor
understands their reasoning for services that are more extensive than is typical for the
condition treated. A separate statement is not required if the record justifies treatment
without further explanation.
Limits on Requirements. Contractors shall not require more specific documentation
unless other Medicare manual policies require it. Contractors may request further
information to be included in these documents concerning specific cases under review
when that information is relevant, but not submitted with records.
Dictated Documentation. For Medicare purposes, dictated therapy documentation is
considered completed on the day it was dictated. The qualified professional may edit and
electronically sign the documentation at a later date.
Dates for Documentation. The date the documentation was made is important only to
establish the date of the initial plan of care because therapy cannot begin until the plan is
established unless treatment is performed or supervised by the same clinician who
establishes the plan. However, contractors may require that treatment notes and progress
reports be entered into the record within 1 week of the last date to which the progress
report or treatment note refers. For example, if treatment began on the first of the month
at a frequency of twice a week, a progress report would be required at the end of the
month. Contractors may require that the progress report that describes that month of
treatment be dated not more than 1 week after the end of the month described in the
report.
Document Information to Meet Requirements. In preparing records, clinicians must be
familiar with the requirements for covered and payable outpatient therapy services. For
example, the records should justify:
• The patient is under the care of a physician/NPP;
Physician/NPP care shall be documented by physician/NPP certification
(approval) of the plan of care; and
Although not required, other evidence of physician/NPP involvement in the
patient’s care may include, for example: order/referral, conference, team
meeting notes, and correspondence.
• Services require the skills of a therapist.
Services must not only be provided by the qualified professional or qualified
personnel, but they must require, for example, the expertise, knowledge,
clinical judgment, decision making and abilities of a therapist that assistants,
qualified personnel, caretakers or the patient cannot provide independently. A
clinician may not merely supervise, but must apply the skills of a therapist by
actively participating in the treatment of the patient during each progress
report period. In addition, a therapist’s skills may be documented, for
example, by the clinician’s descriptions of their skilled treatment, the changes
made to the treatment due to a clinician’s assessment of the patient’s needs on
a particular treatment day or changes due to progress the clinician judged
sufficient to modify the treatment toward the next more complex or difficult
task.
• Services are of appropriate type, frequency, intensity and duration for the
individual needs of the patient.
Documentation should establish the variables that influence the patient’s
condition, especially those factors that influence the clinician’s decision to
provide more services than are typical for the individual’s condition.
Clinicians and contractors shall determine typical services using published
professional literature and professional guidelines. The fact that services are
typically billed is not necessarily evidence that the services are typically
appropriate. Services that exceed those typically billed should be carefully
documented to justify their necessity, but are payable if the individual patient
benefits from medically necessary services. Also, some services or episodes
of treatment should be less than those typically billed, when the individual
patient reaches goals sooner than is typical.
Documentation should establish through objective measurements that the
patient is making progress toward goals. Note that regression and plateaus
can happen during treatment. It is recommended that the reasons for lack of
progress be noted and the justification for continued treatment be documented
if treatment continues after regression or plateaus.
Needs of the Patient. When a service is reasonable and necessary, the patient
also needs the services. Contractors determine the patient’s needs through
knowledge of the individual patient’s condition, and any complexities that
impact that condition, as described in documentation (usually in the
evaluation, re-evaluation, and progress report). Factors that contribute to need
vary, but in general they relate to such factors as the patient’s diagnoses,
complicating factors, age, severity, time since onset/acuity, self-
efficacy/motivation, cognitive ability, prognosis, and/or medical,
psychological and social stability. Changes in objective and sometimes to
subjective measures of improvement also help establish the need for
rehabilitative services. The use of scientific evidence, obtained from
professional literature, and sequential measurements of the patient’s condition
during treatment is encouraged to support the potential for continued
improvement that may justify the patients need for rehabilitative therapy or
the patient’s need for maintenance therapy.
• Functional information included on claims as required.
The clinician is required to document in the patient’s medical record, using
the G-codes and severity modifiers used in functional reporting, the patient’s
current, projected goal, and discharge status, as reported pursuant to
functional reporting requirements for each date of service for which the
reporting is required. See section 220.4 below for details on documenting G-
code and modifiers. NOTE: Functional reporting and its associated
documentation requirements are no longer applicable for claims or medical
records for dates of service on and after January 1, 2019. See the NOTE at
the beginning of Section 220.4 for more information.
C. Evaluation/Re-Evaluation and Plan of Care
The initial evaluation, or the plan of care including an evaluation, should document the
necessity for a course of therapy through objective findings and subjective patient self-
reporting. Utilize the guidelines of the American Physical Therapy Association, the
American Occupational Therapy Association, or the American Speech-Language and
Hearing Association as guidelines, and not as policy. Only a clinician may perform an
initial examination, evaluation, re-evaluation and assessment or establish a diagnosis or a
plan of care. A clinician may include, as part of the evaluation or re-evaluation, objective
measurements or observations made by a PTA or OTA within their scope of practice, but
the clinician must actively and personally participate in the evaluation or re-evaluation.
The clinician may not merely summarize the objective findings of others or make
judgments drawn from the measurements and/or observations of others.
Documentation of the evaluation should list the conditions and complexities and, where it
is not obvious, describe the impact of the conditions and complexities on the prognosis
and/or the plan for treatment such that it is clear to the contractor who may review the
record that the services planned are appropriate for the individual.
Evaluation shall include:
• A diagnosis (where allowed by state and local law) and description of the specific
problem(s) to be evaluated and/or treated. The diagnosis should be specific and as
relevant to the problem to be treated as possible. In many cases, both a medical diagnosis
(obtained from a physician/NPP) and an impairment based treatment diagnosis related to
treatment are relevant. The treatment diagnosis may or may not be identified by the
therapist, depending on their scope of practice. Where a diagnosis is not allowed, use a
condition description similar to the appropriate ICD code. For example the medical
diagnosis made by the physician is CVA; however, the treatment diagnosis or condition
description for PT may be abnormality of gait, for OT, it may be hemiparesis, and for
SLP, it may be dysphagia. For PT and OT, be sure to include body part evaluated.
Include all conditions and complexities that may impact the treatment. A description
might include, for example, the premorbid function, date of onset, and current function;
• Results of one of the following four measurement instruments are
recommended, but not required:
National Outcomes Measurement System (NOMS) by the American Speech-
Language Hearing Association
Patient Inquiry by Focus On Therapeutic Outcomes, Inc. (FOTO)
Activity Measure – Post Acute Care (AM-PAC)
OPTIMAL by Cedaron through the American Physical Therapy Association
• If results of one of the four instruments above is not recorded, the record shall
contain instead the following information indicated by asterisks (*) and should
contain (but is not required to contain) all of the following, as applicable. Since
published research supports its impact on the need for treatment, information in
the following indented bullets may also be included with the results of the above
four instruments in the evaluation report at the clinician’s discretion. This
information may be incorporated into a test instrument or separately reported
within the required documentation. If it changes, update this information in the
re-evaluation, and/or treatment notes, and/or progress reports, and/or in a separate
record. When it is provided, contractors shall take this documented information
into account to determine whether services are reasonable and necessary.
Documentation supporting illness severity or complexity including, e.g.,
o Identification of other health services concurrently being provided for
this condition (e.g., physician, PT, OT, SLP, chiropractic, nurse,
respiratory therapy, social services, psychology, nutritional/dietetic
services, radiation therapy, chemotherapy, etc.), and/ or
o Identification of durable medical equipment needed for this condition,
and/or
o Identification of the number of medications the beneficiary is taking
(and type if known); and/or
o If complicating factors (complexities) affect treatment, describe why
or how. For example: Cardiac dysrhythmia is not a condition for
which a therapist would directly treat a patient, but in some patients
such dysrhythmias may so directly and significantly affect the pace of
progress in treatment for other conditions as to require an exception to
caps for necessary services. Documentation should indicate how the
progress was affected by the complexity. Or, the severity of the
patient’s condition as reported on a functional measurement tool may
be so great as to suggest extended treatment is anticipated; and/or
o Generalized or multiple conditions. The beneficiary has, in addition to
the primary condition being treated, another disease or condition being
treated, or generalized musculoskeletal conditions, or conditions
affecting multiple sites and these conditions will directly and
significantly impact the rate of recovery; and/or.
o Mental or cognitive disorder. The beneficiary has a mental or
cognitive disorder in addition to the condition being treated that will
directly and significantly impact the rate of recovery; and/or.
o Identification of factors that impact severity including e.g., age, time
since onset, cause of the condition, stability of symptoms, how
typical/atypical are the symptoms of the diagnosed condition,
availability of an intervention/treatment known to be effective,
predictability of progress.
Documentation supporting medical care prior to the current episode, if any,
(or document none) including, e.g.,
o Record of discharge from a Part A qualifying inpatient, SNF, or home
health episode within 30 days of the onset of this outpatient therapy
episode, or
o Identification of whether beneficiary was treated for this same
condition previously by the same therapy discipline (regardless of
where prior services were furnished; and
o Record of a previous episode of therapy treatment from the same or
different therapy discipline in the past year.
Documentation required to indicate beneficiary health related to quality of
life, specifically,
o The beneficiary’s response to the following question of self-related
health: “At the present time, would you say that your health is
excellent, very good, fair, or poor?” If the beneficiary is unable to
respond, indicate why; and
Documentation required to indicate beneficiary social support including,
specifically,
o Where does the beneficiary live (or intend to live) at the conclusion of
this outpatient therapy episode? (e.g., private home, private apartment,
rented room, group home, board and care apartment, assisted living,
SNF), and
o Who does beneficiary live with (or intend to live with) at the
conclusion of this outpatient therapy episode? (e.g., lives alone,
spouse/significant other, child/children, other relative, unrelated
person(s), personal care attendant), and
o Does the beneficiary require this outpatient therapy plan of care in
order to return to a premorbid (or reside in a new) living environment,
and
o Does the beneficiary require this outpatient therapy plan of care in
order to reduce Activities of Daily Living (ADL) or Instrumental
Activities of Daily Living or (IADL) assistance to a premorbid level or
to reside in a new level of living environment (document prior level of
independence and current assistance needs); and
*Documentation required to indicate objective, measurable beneficiary
physical function including, e.g.,
o Functional assessment individual item and summary scores (and
comparisons to prior assessment scores) from commercially available
therapy outcomes instruments other than those listed above; or
o Functional assessment scores (and comparisons to prior assessment
scores) from tests and measurements validated in the professional
literature that are appropriate for the condition/function being
measured; or
o Other measurable progress towards identified goals for functioning in
the home environment at the conclusion of this therapy episode of
care.
• Clinician’s clinical judgments or subjective impressions that describe the current
functional status of the condition being evaluated, when they provide further information
to supplement measurement tools; and
• A determination that treatment is not needed, or, if treatment is needed a
prognosis for return to premorbid condition or maximum expected condition with
expected time frame and a plan of care.
NOTE: When the Evaluation Serves as the Plan of Care. When an evaluation is the only
service provided by a provider/supplier in an episode of treatment, the evaluation serves
as the plan of care if it contains a diagnosis, or in states where a therapist may not
diagnose, a description of the condition from which a diagnosis may be determined by
the referring physician/NPP. The goal, frequency, and duration of treatment are implied
in the diagnosis and one-time service. The referral/order of a physician/NPP is the
certification that the evaluation is needed and the patient is under the care of a physician.
Therefore, when evaluation is the only service, a referral/order and evaluation are the
only required documentation. If the patient presented for evaluation without a referral or
order and does not require treatment, a physician referral/order or certification of the
evaluation is required for payment of the evaluation. A referral/order dated after the
evaluation shall be interpreted as certification of the plan to evaluate the patient.
The time spent in evaluation shall not also be billed as treatment time. Evaluation
minutes are untimed and are part of the total treatment minutes, but minutes of evaluation
shall not be included in the minutes for timed codes reported in the treatment notes.
Re-evaluations shall be included in the documentation sent to contractors when a re-
evaluation has been performed. See the definition in section 220. Re-evaluations are
usually focused on the current treatment and might not be as extensive as initial
evaluations. Continuous assessment of the patient's progress is a component of ongoing
therapy services and is not payable as a re-evaluation. A re-evaluation is not a routine,
recurring service but is focused on evaluation of progress toward current goals, making a
professional judgment about continued care, modifying goals and/or treatment or
terminating services. A formal re-evaluation is covered only if the documentation
supports the need for further tests and measurements after the initial evaluation.
Indications for a re-evaluation include new clinical findings, a significant change in the
patient's condition, or failure to respond to the therapeutic interventions outlined in the
plan of care.
A re-evaluation may be appropriate prior to planned discharge for the purposes of
determining whether goals have been met, or for the use of the physician or the treatment
setting at which treatment will be continued.
A re-evaluation is focused on evaluation of progress toward current goals and making a
professional judgment about continued care, modifying goals and/or treatment or
terminating services. Reevaluation requires the same professional skills as evaluation.
The minutes for re-evaluation are documented in the same manner as the minutes for
evaluation. Current Procedural Terminology does not define a re-evaluation code for
speech-language pathology; use the evaluation code.
Plan of Care. See section 220.1.2 for requirements of the plan. The evaluation and plan
may be reported in two separate documents or a single combined document.
D. Progress Report
The progress report provides justification for the medical necessity of treatment.
Contractors shall determine the necessity of services based on the delivery of services as
directed in the plan and as documented in the treatment notes and progress report. For
Medicare payment purposes, information required in progress reports shall be written by
a clinician that is, either the physician/NPP who provides or supervises the services, or by
the therapist who provides the services and supervises an assistant. It is not required that
the referring or supervising physician/NPP sign the progress reports written by a PT, OT
or SLP.
Timing. The minimum progress report period shall be at least once every 10 treatment
days. The day beginning the first reporting period is the first day of the episode of
treatment regardless of whether the service provided on that day is an evaluation, re-
evaluation or treatment. Regardless of the date on which the report is actually written
(and dated), the end of the progress report period is either a date chosen by the clinician
or the 10
th
treatment day, whichever is shorter. The next treatment day begins the next
reporting period. The progress report period requirements are complete when both the
elements of the progress report and the clinician’s active participation in treatment have
been documented.
For example, for a patient evaluated on Monday, October 1 and being treated five times a
week, on weekdays: On October 5, (before it is required), the clinician may choose to
write a progress report for the last week’s treatment (from October 1 to October 5).
October 5 ends the reporting period and the next treatment on Monday, October 8 begins
the next reporting period. If the clinician does not choose to write a report for the next
week, the next report is required to cover October 8 through October 19, which would be
10 treatment days.
It should be emphasized that the dates for recertification of plans of care do not affect the
dates for required progress reports. (Consideration of the case in preparation for a report
may lead the therapist to request early recertification. However, each report does not
require recertification of the plan, and there may be several reports between
recertifications). In many settings, weekly progress reports are voluntarily prepared to
review progress, describe the skilled treatment, update goals, and inform physician/NPPs
or other staff. The clinical judgment demonstrated in frequent reports may help justify
that the skills of a therapist are being applied, and that services are medically necessary.
Absences. Holidays, sick days or other patient absences may fall within the progress
report period. Days on which a patient does not encounter qualified professional or
qualified personnel for treatment, evaluation or re-evaluation do not count as treatment
days. However, absences do not affect the requirement for a progress report at least once
during each progress report period. If the patient is absent unexpectedly at the end of the
reporting period, when the clinician has not yet provided the required active participation
during that reporting period, a progress report is still required, but without the clinician’s
active participation in treatment, the requirements of the progress report period are
incomplete.
Delayed Reports. If the clinician has not written a progress report before the end of the
progress reporting period, it shall be written within 7 calendar days after the end of the
reporting period. If the clinician did not participate actively in treatment during the
progress report period, documentation of the delayed active participation shall be entered
in the treatment note as soon as possible. The treatment note shall explain the reason for
the clinician’s missed active participation. Also, the treatment note shall document the
clinician’s guidance to the assistant or qualified personnel to justify that the skills of a
therapist were required during the reporting period. It is not necessary to include in this
treatment note any information already recorded in prior treatment notes or progress
reports.
The contractor shall make a clinical judgment whether continued treatment by assistants
or qualified personnel is reasonable and necessary when the clinician has not actively
participated in treatment for longer than one reporting period. Judgment shall be based
on the individual case and documentation of the application of the clinician’s skills to
guide the assistant or qualified personnel during and after the reporting period.
Early Reports. Often, progress reports are written weekly, or even daily, at the discretion
of the clinician. Clinicians are encouraged, but not required to write progress reports
more frequently than the minimum required in order to allow anyone who reviews the
records to easily determine that the services provided are appropriate, covered and
payable.
Elements of progress reports may be written in the treatment notes if the
provider/supplier or clinician prefers. If each element required in a progress report is
included in the treatment notes at least once during the progress report period, then a
separate progress report is not required. Also, elements of the progress report may be
incorporated into a revised plan of care when one is indicated. Although the progress
report written by a therapist does not require a physician/NPP signature when written as a
stand-alone document, the revised plan of care accompanied by the progress report shall
be re-certified by a physician/NPP. See section 220.1.2C, Changes to the Therapy Plan,
for guidance on when a revised plan requires certification.
Progress Reports for Services Billed Incident to a Physician’s Service. The policy for
incident to services requires, for example, the physician’s initial service, direct
supervision of therapy services, and subsequent services of a frequency which reflect
his/her active participation in and management of the course of treatment (see section
60.1B of this chapter. Also, see the billing requirements for services incident to a
physician in Pub. 100-04, chapter 26, Items 17, 19, 24, and 31.) Therefore, supervision
and reporting requirements for supervising physician/NPPs supervising staff are the same
as those for PTs and OTs supervising PTAs and OTAs with certain exceptions noted
below.
When a therapy service is provided by a therapist, supervised by a physician/NPP and
billed incident to the services of the physician/NPP, the progress report shall be written
and signed by the therapist who provides the services.
When the services incident to a physician are provided by qualified personnel who are
not therapists, the ordering or supervising physician/NPP must personally provide at least
one treatment session during each progress report period and sign the progress report.
Documenting Clinician Participation in Treatment in the Progress Report. Verification of
the clinician’s required participation in treatment during the progress report period shall
be documented by the clinician’s signature on the treatment note and/or on the progress
report. When unexpected discontinuation of treatment occurs, contractors shall not
require a clinician’s participation in treatment for the incomplete reporting period.
The Discharge Note (or Discharge Summary) is required for each episode of outpatient
treatment. In provider settings where the physician/NPP writes a discharge summary and
the discharge documentation meets the requirements of the provider setting, a separate
discharge note written by a therapist is not required. The discharge note shall be a
progress report written by a clinician, and shall cover the reporting period from the last
progress report to the date of discharge. In the case of a discharge unanticipated in the
plan or previous progress report, the clinician may base any judgments required to write
the report on the treatment notes and verbal reports of the assistant or qualified personnel.
In the case of a discharge anticipated within 3 treatment days of the progress report, the
clinician may provide objective goals which, when met, will authorize the assistant or
qualified personnel to discharge the patient. In that case, the clinician should verify that
the services provided prior to discharge continued to require the skills of a therapist, and
services were provided or supervised by a clinician. The discharge note shall include all
treatment provided since the last progress report and indicate that the therapist reviewed
the notes and agrees to the discharge.
At the discretion of the clinician, the discharge note may include additional information;
for example, it may summarize the entire episode of treatment, or justify services that
may have extended beyond those usually expected for the patient’s condition. Clinicians
should consider the discharge note the last opportunity to justify the medical necessity of
the entire treatment episode in case the record is reviewed. The record should be
reviewed and organized so that the required documentation is ready for presentation to
the contractor if requested.
Assistant’s Participation in the Progress Report. PTAs or OTAs may write elements of
the progress report dated between clinician reports. Reports written by assistants are not
complete progress reports. The clinician must write a progress report during each
progress report period regardless of whether the assistant writes other reports. However,
reports written by assistants are part of the record and need not be copied into the
clinicians report. Progress reports written by assistants supplement the reports of
clinicians and shall include:
• Date of the beginning and end of the reporting period that this report refers to;
• Date that the report was written (not required to be within the reporting period);
• Signature, and professional identification, or for dictated documentation, the
identification of the qualified professional who wrote the report and the date on which it
was dictated;
• Objective reports of the patient’s subjective statements, if they are relevant. For
example, “Patient reports pain after 20 repetitions”. Or, “The patient was not feeling well
on 11/05/06 and refused to complete the treatment session.”; and
• Objective measurements (preferred) or description of changes in status relative to
each goal currently being addressed in treatment, if they occur. Note that assistants may
not make clinical judgments about why progress was or was not made, but may report the
progress objectively. For example: “increasing strength” is not an objective
measurement, but “patient ambulates 15 feet with maximum assistance” is objective.
Descriptions shall make identifiable reference to the goals in the current plan of care.
Since only long term goals are required in the plan of care, the progress report may be
used to add, change or delete short term goals. Assistants may change goals only under
the direction of a clinician. When short term goal changes are dictated to an assistant or
to qualified personnel, report the change, clinician’s name, and date. Clinicians verify
these changes by co-signatures on the report or in the clinician’s progress report. (See
section 220.1.2(C) to modify the plan for changes in long term goals).
The evaluation and plan of care are considered incorporated into the progress report, and
information in them is not required to be repeated in the report. For example, if a time
interval for the treatment is not specifically stated, it is assumed that the goals refer to the
plan of care active for the current progress report period. If a body part is not specifically
noted, it is assumed the treatment is consistent with the evaluation and plan of care.
Any consistent method of identifying the goals may be used. Preferably, the long term
goals may be numbered (1, 2, 3,) and the short term goals that relate to the long term
goals may be numbered and lettered 1.A, 1.B, etc. The identifier of a goal on the plan of
care may not be changed during the episode of care to which the plan refers. A clinician,
an assistant on the order of a therapist or qualified personnel on the order of a
physician/NPP shall add new goals with new identifiers or letters. Omit reference to a
goal after a clinician has reported it to be met, and that clinician’s signature verifies the
change.
Content of Clinician (Therapist, Physician/NPP) Progress Reports. In addition to the
requirements above for notes written by assistants, the progress report of a clinician shall
also include:
• Assessment of improvement, extent of progress (or lack thereof) toward each
goal;
• Plans for continuing treatment, reference to additional evaluation results, and/or
treatment plan revisions should be documented in the clinician’s progress report; and
• Changes to long or short term goals, discharge or an updated plan of care that is
sent to the physician/NPP for certification of the next interval of treatment.
• Functional documentation is required as part of the progress report at the end of
each progress reporting period. It is also required at the time of discharge on the
discharge note or summary, as applicable. The clinician documents, on the applicable
dates of service, the specific nonpayable G-codes and severity modifiers used in the
required reporting of the patient’s functional limitation(s) on the claim for services,
including how the modifier selection was made. See subsection C of 220.4 below for
details relevant to documentation requirements.
A re-evaluation should not be required before every progress report routinely, but may be
appropriate when assessment suggests changes not anticipated in the original plan of
care.
Care must be taken to assure that documentation justifies the necessity of the services
provided during the reporting period, particularly when reports are written at the
minimum frequency. Justification for treatment must include, for example, objective
evidence or a clinically supportable statement of expectation that:
• In the case of rehabilitative therapy, the patient’s condition has the potential to
improve or is improving in response to therapy, maximum improvement is yet to
be attained; and there is an expectation that the anticipated improvement is
attainable in a reasonable and generally predictable period of time.
• In the case of maintenance therapy, treatment by the therapist is necessary to
maintain, prevent or slow further deterioration of the patient’s functional status
and the services cannot be safely carried out by the beneficiary him or herself, a
family member, another caregiver or unskilled personnel.
Objective evidence consists of standardized patient assessment instruments, outcome
measurements tools or measurable assessments of functional outcome. Use of objective
measures at the beginning of treatment, during and/or after treatment is recommended to
quantify progress and support justifications for continued treatment. Such tools are not
required, but their use will enhance the justification for needed therapy.
Example: The Plan states diagnosis is 787.2- Dysphagia secondary to other late effects
of CVA. Patient is on a restricted diet and wants to drink thick liquids. Therapy is
planned 3X week, 45 minute sessions for 6 weeks. Long term goal is to consume a
mechanical soft diet with thin liquids without complications such as aspiration
pneumonia. Short Term Goal 1: Patient will improve rate of laryngeal elevation/timing
of closure by using the super-supraglottic swallow on saliva swallows without cues on
90% of trials. Goal 2: Patient will compensate for reduced laryngeal elevation by
controlling bolus size to ½ teaspoon without cues 100%. The progress report for 1/3/06
to 1/29/06 states: 1. Improved to 80% of trials; 2. Achieved. Comments: Highly
motivated; spouse assists with practicing, compliant with current restrictions. New Goal:
“5. Patient will implement above strategies to swallow a sip of water without coughing
for 5 consecutive trials. Mary Johns, CCC-SLP, 1/29/06.” Note the provider is billing
92526 three times a week, consistent with the plan; progress is documented; skilled
treatment is documented.
E. Treatment Note
The purpose of these notes is simply to create a record of all treatments and skilled
interventions that are provided and to record the time of the services in order to justify the
use of billing codes on the claim. Documentation is required for every treatment day, and
every therapy service. The format shall not be dictated by contractors and may vary
depending on the practice of the responsible clinician and/or the clinical setting.
The treatment note is not required to document the medical necessity or appropriateness
of the ongoing therapy services. Descriptions of skilled interventions should be included
in the plan or the progress reports and are allowed, but not required daily. Non-skilled
interventions need not be recorded in the treatment notes as they are not billable.
However, notation of non-skilled treatment or report of activities performed by the
patient or non-skilled staff may be reported voluntarily as additional information if they
are relevant and not billed. Specifics such as number of repetitions of an exercise and
other details included in the plan of care need not be repeated in the treatment notes
unless they are changed from the plan.
Documentation of each treatment shall include the following required elements:
• Date of treatment; and
• Identification of each specific intervention/modality provided and billed, for
both timed and untimed codes, in language that can be compared with the billing on the
claim to verify correct coding. Record each service provided that is represented by a
timed code, regardless of whether or not it is billed, because the unbilled timed services
may impact the billing; and
• Total timed code treatment minutes and total treatment time in minutes. Total
treatment time includes the minutes for timed code treatment and untimed code
treatment. Total treatment time does not include time for services that are not billable
(e.g., rest periods). For Medicare purposes, it is not required that unbilled services that
are not part of the total treatment minutes be recorded, although they may be included
voluntarily to provide an accurate description of the treatment, show consistency with the
plan, or comply with state or local policies. The amount of time for each specific
intervention/modality provided to the patient may also be recorded voluntarily, but
contractors shall not require it, as it is indicated in the billing. The billing and the total
timed code treatment minutes must be consistent. See Pub. 100-04, chapter 5, section
20.2 for description of billing timed codes; and
• Signature and professional identification of the qualified professional who
furnished or supervised the services and a list of each person who contributed to that
treatment (i.e., the signature of Kathleen Smith, PTA, with notation of phone consultation
with Judy Jones, PT, supervisor, when permitted by state and local law). The signature
and identification of the supervisor need not be on each treatment note, unless the
supervisor actively participated in the treatment. Since a clinician must be identified on
the plan of care and the progress report, the name and professional identification of the
supervisor responsible for the treatment is assumed to be the clinician who wrote the plan
or report. When the treatment is supervised without active participation by the
supervisor, the supervisor is not required to cosign the treatment note written by a
qualified professional. When the responsible supervisor is absent, the presence of a
similarly qualified supervisor on the clinic roster for that day is sufficient documentation
and it is not required that the substitute supervisor sign or be identified in the
documentation.
If a treatment is added or changed under the direction of a clinician during the treatment
days between the progress reports, the change must be recorded and justified on the
medical record, either in the treatment note or the progress report, as determined by the
policies of the provider/supplier. New exercises added or changes made to the exercise
program help justify that the services are skilled. For example: The original plan was for
therapeutic activities, gait training and neuromuscular re-education. “On Feb. 1 clinician
added electrical stim. to address shoulder pain.”
Documentation of each treatment may also include the following optional elements to be
mentioned only if the qualified professional recording the note determines they are
appropriate and relevant. If these are not recorded daily, any relevant information should
be included in the progress report.
• Patient self-report;
• Adverse reaction to intervention;
• Communication/consultation with other providers (e.g., supervising clinician,
attending physician, nurse, another therapist, etc.);
• Significant, unusual or unexpected changes in clinical status;
• Equipment provided; and/or
• Any additional relevant information the qualified professional finds
appropriate.
See Pub. 100-04, Medicare Claims Processing Manual, chapter 5, section 20.2 for
instructions on how to count minutes. It is important that the total number of timed
treatment minutes support the billing of units on the claim, and that the total treatment
time reflects services billed as untimed codes.
220.4 – Functional Reporting
(Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19)
NOTE: In the calendar year (CY) 2019 Physician Fee Schedule (PFS) final rule, CMS-1693-
F, after consideration of stakeholder comments for burden reduction, a review of all of the
requirements under section 3005(g) of Middle Class Tax Relief and Jobs Creation Act of
2012 (MCTRJCA), and in light of the statutory amendments to section 1833(g) of the Act,
via section 50202 of Bipartisan Budget Act of 2018 to repeal the therapy caps, CMS
concluded that continued collection of functional reporting data through the same or reduced
format would not yield additional information to inform future analyses or to serve as a basis
for reforms to the payment system for therapy services. To reduce the burden of reporting
for providers of therapy services, the CY 2019 PFS final rule ended the requirements of
reporting the functional limitation nonpayable HCPCS G-codes and severity modifiers on
claims for therapy services and the associated documentation requirements in medical
records, effective for dates of service on and after January 1, 2019. The rule also revised
regulation text at 42 CFR 410.59, 410.60, 410.61, 410.62, 410.105, accordingly.
The instructions below apply only to dates of service when the functional reporting
requirements were effective, January 1, 2013 through December 31, 2018.
A. Selecting the G-codes to Use in Functional Reporting.
There are 42 functional G-codes, 14 sets of three codes each, for that can be used in
identifying the functional limitation being reported. Six of the G-code sets are generally
for PT and OT functional limitations and eight sets of G-codes are for SLP functional
limitations. (For a list of these codes and descriptors, see Pub. 100-04, Medicare Claims
Processing Manual, chapter 5, section 10.6 F.)
Only one functional limitation shall be reported at a time. Consequently, the clinician
must select the G-code set for the functional limitation that most closely relates to the
primary functional limitation being treated or the one that is the primary reason for
treatment. When the beneficiary has more than one functional limitation, the clinician
may need to make a determination as to which functional limitation is primary. In these
cases, the clinician may choose the functional limitation that is:
• Most clinically relevant to a successful outcome for the beneficiary;
• The one that would yield the quickest and/or greatest functional progress; or
• The one that is the greatest priority for the beneficiary.
In all cases, this primary functional limitation should reflect the predominant limitation
that the furnished therapy services are intended to address.
For services typically reported as PT or OT, the clinician reports one of the “Other
PT/OT” functional G-codes sets to report when one of the four PT/OT categorical code
sets does not describe the beneficiary’s functional limitation, as follows:
• a beneficiary’s functional limitation that is not defined by one of the four
categories;
• a beneficiary whose therapy services are not intended to treat a functional
limitation; or
• a beneficiary’s functional limitation where an overall, composite, or other score
from a functional assessment tool is used and does not clearly represent a
functional limitation defined by one of the above four categorical PT/OT code
sets.
In addition, the subsequent “Other PT/OT” G-code set is only reported after the primary
“Other PT/OT” G-code set has been reported for the beneficiary during the same episode
of care.
For services typically reported as SLP services, the clinician uses the “Other SLP”
functional G-code to report when the functional limitation being treated is not represented
by one of the seven categorical SLP functional measures. In addition, the “Other SLP”
G-code set is used to report where an overall, composite, or other score from an
assessment tool that does not clearly represent a functional limitation defined by one of
the seven categorical SLP measures.
B. Selecting the severity modifiers to use in functional reporting/documenting.
Each G-code requires one of the following severity modifiers. When the clinician reports
any of the following a modifier is used to convey the severity of the functional limitation:
current status, the goal status and the discharge status.
Modifier
Impairment Limitation Restriction
CH
0 percent impaired, limited or restricted
CI
At least 1 percent but less than 20 percent impaired, limited or restricted
CJ
At least 20 percent but less than 40 percent impaired, limited or restricted
CK
At least 40 percent but less than 60 percent impaired, limited or restricted
CL
At least 60 percent but less than 80 percent impaired, limited or restricted
CM
At least 80 percent but less than 100 percent impaired, limited or restricted
CN
100 percent impaired, limited or restricted
The severity modifier reflects the beneficiary’s percentage of functional impairment as
determined by the clinician furnishing the therapy services for each functional status:
current, goal, or discharge. In selecting the severity modifier, the clinician:
• Uses the severity modifier that reflects the score from a functional assessment tool
or other performance measurement instrument, as appropriate.
• Uses his/her clinical judgment to combine the results of multiple measurement
tools used during the evaluative process to inform clinical decision making to
determine a functional limitation percentage.
• Uses his/her clinical judgment in the assignment of the appropriate modifier.
• Uses the CH modifier to reflect a zero percent impairment when the therapy
services being furnished are not intended to treat (or address) a functional
limitation.
In some cases the modifier will be the same for current status and goal status. For
example: where improvement is expected but it is not expected to be enough to move to
another modifier, such as from 10 percent to 15 percent, the same severity modifier
would be used in reporting the current and goal status. Also, when the clinician does not
expect improvement, such as for individuals receiving maintenance therapy, the modifier
used for projected goal status will be the same as the one for current status. In these
cases, the discharge status may also include the same modifier.
Therapists must document in the medical record how they made the modifier selection so
that the same process can be followed at succeeding assessment intervals.
C. Documentation of G-code and Severity Modifier Selection.
Documentation of the nonpayable G-codes and severity modifiers regarding functional
limitations reported on claims must be included in the patient’s medical record of therapy
services for each required reporting. (See Pub. 100-04, Medicare Claims Processing
Manual, chapter 5, section 10.6 for details about the functional reporting requirements on
claims for therapy services, including PT, OT, and SLP services furnished in CORFs.)
Documentation of functional reporting in the medical record of therapy services must be
completed by the clinician furnishing the therapy services:
• The qualified therapist furnishing the therapy services
• The physician/NPP personally furnishing the therapy services
• The qualified therapist furnishing services incident to the physician/NPP
• The physician/NPP for incident to services furnished by qualified personnel, who
are not qualified therapists.
The qualified therapist furnishing the PT, OT, or SLP services in a CORF.
230 - Practice of Physical Therapy, Occupational Therapy, and Speech-
Language Pathology
(Rev. 63, Issued: 12-29-06, Effective: 01-01-07, Implementation: on or before 01-29-
07)
A. Group Therapy Services. Contractors pay for outpatient physical therapy services
(which includes outpatient speech-language pathology services) and outpatient
occupational therapy services provided simultaneously to two or more individuals by a
practitioner as group therapy services (97150). The individuals can be, but need not be
performing the same activity. The physician or therapist involved in group therapy
services must be in constant attendance, but one-on-one patient contact is not required.
B. Therapy Students
1. General
Only the services of the therapist can be billed and paid under Medicare Part B. The
services performed by a student are not reimbursed even if provided under “line of sight”
supervision of the therapist; however, the presence of the student “in the room” does not
make the service unbillable. Pay for the direct (one-to-one) patient contact services of
the physician or therapist provided to Medicare Part B patients. Group therapy services
performed by a therapist or physician may be billed when a student is also present “in the
room”.
EXAMPLES:
Therapists may bill and be paid for the provision of services in the following scenarios:
• The qualified practitioner is present and in the room for the entire session. The
student participates in the delivery of services when the qualified practitioner is
directing the service, making the skilled judgment, and is responsible for the
assessment and treatment.
• The qualified practitioner is present in the room guiding the student in service
delivery when the therapy student and the therapy assistant student are participating
in the provision of services, and the practitioner is not engaged in treating another
patient or doing other tasks at the same time.
• The qualified practitioner is responsible for the services and as such, signs all
documentation. (A student may, of course, also sign but it is not necessary since the
Part B payment is for the clinician’s service, not for the student’s services).
2. Therapy Assistants as Clinical Instructors
Physical therapist assistants and occupational therapy assistants are not precluded from
serving as clinical instructors for therapy students, while providing services within their
scope of work and performed under the direction and supervision of a licensed physical
or occupational therapist to a Medicare beneficiary.
3. Services Provided Under Part A and Part B
The payment methodologies for Part A and B therapy services rendered by a student are
different. Under the MPFS (Medicare Part B), Medicare pays for services provided by
physicians and practitioners that are specifically authorized by statute. Students do not
meet the definition of practitioners under Medicare Part B. Under SNF PPS, payments
are based upon the case mix or Resource Utilization Group (RUG) category that
describes the patient. In the rehabilitation groups, the number of therapy minutes
delivered to the patient determines the RUG category. Payment levels for each category
are based upon the costs of caring for patients in each group rather than providing
specific payment for each therapy service as is done in Medicare Part B.
230.1 - Practice of Physical Therapy
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)
A. General
Physical therapy services are those services provided within the scope of practice of
physical therapists and necessary for the diagnosis and treatment of impairments,
functional limitations, disabilities or changes in physical function and health status. (See
Pub. 100-03, the Medicare National Coverage Determinations Manual, for specific
conditions or services.) For descriptions of aquatic therapy in a community center pool
see section 220C of this chapter.
B. Qualified Physical Therapist Defined
Reference: 42CFR484.4
The new personnel qualifications for physical therapists were discussed in the 2008
Physician Fee Schedule. See the Federal Register of November 27, 2007, for the full
text. See also the correction notice for this rule, published in the Federal Register on
January 15, 2008.
The regulation provides that a qualified physical therapist (PT) is a person who is
licensed, if applicable, as a PT by the state in which he or she is practicing unless
licensure does not apply, has graduated from an accredited PT education program and
passed a national examination approved by the state in which PT services are provided.
The phrase, “by the state in which practicing” includes any authorization to practice
provided by the same state in which the service is provided, including temporary
licensure, regardless of the location of the entity billing the services. The curriculum
accreditation is provided by the Commission on Accreditation in Physical Therapy
Education (CAPTE) or, for those who graduated before CAPTE, curriculum approval
was provided by the American Physical Therapy Association (APTA). For
internationally educated PTs, curricula are approved by a credentials evaluation
organization either approved by the APTA or identified in 8 CFR 212.15(e) as it relates
to PTs. For example, in 2007, 8 CFR 212.15(e) approved the credentials evaluation
provided by the Federation of State Boards of Physical Therapy (FSBPT) and the Foreign
Credentialing Commission on Physical Therapy (FCCPT). The requirements above
apply to all PTs effective January 1, 2010, if they have not met any of the following
requirements prior to January 1, 2010.
Physical therapists whose current license was obtained on or prior to December 31, 2009,
qualify to provide PT services to Medicare beneficiaries if they:
• graduated from a CAPTE approved program in PT on or before December 31,
2009 (examination is not required); or,
• graduated on or before December 31, 2009, from a PT program outside the U.S.
that is determined to be substantially equivalent to a U.S. program by a
credentials evaluating organization approved by either the APTA or identified in
8 CFR 212.15(e) and also passed an examination for PTs approved by the state in
which practicing.
Or, PTs whose current license was obtained before January 1, 2008, may meet the
requirements in place on that date (i.e., graduation from a curriculum approved by
either the APTA, the Committee on Allied Health Education and Accreditation of
the American Medical Association, or both).
Or, PTs meet the requirements who are currently licensed and were licensed or
qualified as a PT on or before December 31, 1977, and had 2 years appropriate
experience as a PT, and passed a proficiency examination conducted, approved, or
sponsored by the U.S. Public Health Service.
Or, PTs meet the requirements if they are currently licensed and before January 1,
1966, they were:
• admitted to membership by the APTA; or
• admitted to registration by the American Registry of Physical Therapists;
or
• graduated from a 4-year PT curriculum approved by a State Department of
Education; or
• licensed or registered and prior to January 1, 1970, they had 15 years of
full-time experience in PT under the order and direction of attending and
referring doctors of medicine or osteopathy.
Or, PTs meet requirements if they are currently licensed and they were trained
outside the U.S. before January 1, 2008, and after 1928 graduated from a PT
curriculum approved in the country in which the curriculum was located, if that
country had an organization that was a member of the World Confederation for
Physical Therapy, and that PT qualified as a member of the organization.
For outpatient PT services that are provided incident to the services of physicians/NPPs,
the requirement for PT licensure does not apply; all other personnel qualifications do
apply. The qualified personnel providing PT services incident to the services of a
physician/NPP must be trained in an accredited PT curriculum. For example, a person
who, on or before December 31, 2009, graduated from a PT curriculum accredited by
CAPTE, but who has not passed the national examination or obtained a license, could
provide Medicare outpatient PT therapy services incident to the services of a
physician/NPP if the physician assumes responsibility for the services according to the
incident to policies. On or after January 1, 2010, although licensure does not apply, both
education and examination requirements that are effective January 1, 2010, apply to
qualified personnel who provide PT services incident to the services of a physician/NPP.
C. Services of Physical Therapy Support Personnel
Reference: 42CFR 484.4
Personnel Qualifications. The new personnel qualifications for physical therapist
assistants (PTA) were discussed in the 2008 Physician Fee Schedule. See the Federal
Register of November 27, 2007, for the full text. See also the correction notice for this
rule, published in the Federal Register on January 15, 2008.
The regulation provides that a qualified PTA is a person who is licensed as a PTA unless
licensure does not apply, is registered or certified, if applicable, as a PTA by the state in
which practicing, and graduated from an approved curriculum for PTAs, and passed a
national examination for PTAs. The phrase, “by the state in which practicing” includes
any authorization to practice provided by the same state in which the service is provided,
including temporary licensure, regardless of the location or the entity billing for the
services. Approval for the curriculum is provided by CAPTE or, if internationally or
military trained PTAs apply, approval will be through a credentialing body for the
curriculum for PTAs identified by either the American Physical Therapy Association or
identified in 8 CFR 212.15(e). A national examination for PTAs is, for example the one
furnished by the Federation of State Boards of Physical Therapy. These requirements
above apply to all PTAs effective January 1, 2010, if they have not met any of the
following requirements prior to January 1, 2010.
Those PTAs also qualify who, on or before December 31, 2009, are licensed, registered
or certified as a PTA and met one of the two following requirements:
1. Is licensed or otherwise regulated in the state in which practicing; or
2. In states that have no licensure or other regulations, or where licensure does
not apply, PTAs have:
o graduated on or before December 31, 2009, from a 2-year college-level
program approved by the APTA or CAPTE; and
o effective January 1, 2010, those PTAs must have both graduated from a
CAPTE approved curriculum and passed a national examination for PTAs;
or
PTAs may also qualify if they are licensed, registered or certified as a PTA, if applicable
and meet requirements in effect before January 1, 2008, that is,
• they have graduated before January 1, 2008, from a 2 year college level
program approved by the APTA; or
• on or before December 31, 1977, they were licensed or qualified as a PTA and
passed a proficiency examination conducted, approved, or sponsored by the
U.S. Public Health Service.
Services. The services of PTAs used when providing covered therapy benefits are
included as part of the covered service. These services are billed by the supervising
physical therapist. PTAs may not provide evaluative or assessment services, make
clinical judgments or decisions; develop, manage, or furnish skilled maintenance program
services; or take responsibility for the service. They act at the direction and under the
supervision of the treating physical therapist and in accordance with state laws.
A physical therapist must supervise PTAs. The level and frequency of supervision differs
by setting (and by state or local law). General supervision is required for PTAs in all
settings except private practice (which requires direct supervision) unless state practice
requirements are more stringent, in which case state or local requirements must be
followed. See specific settings for details. For example, in clinics, rehabilitation
agencies, and public health agencies, 42CFR485.713 indicates that when a PTA provides
services, either on or off the organization’s premises, those services are supervised by a
qualified physical therapist who makes an onsite supervisory visit at least once every 30
days or more frequently if required by state or local laws or regulation.
The services of a PTA shall not be billed as services incident to a physician/NPP’s
service, because they do not meet the qualifications of a therapist.
The cost of supplies (e.g., theraband, hand putty, electrodes) used in furnishing covered
therapy care is included in the payment for the HCPCS codes billed by the physical
therapist, and are, therefore, not separately billable. Separate coverage and billing
provisions apply to items that meet the definition of brace in §130.
Services provided by aides, even if under the supervision of a therapist, are not therapy
services and are not covered by Medicare. Although an aide may help the therapist by
providing unskilled services, those services that are unskilled are not covered by
Medicare and shall be denied as not reasonable and necessary if they are billed as therapy
services.
D. Application of Medicare Guidelines to PT Services
This subsection will be used in the future to illustrate the application of the above
guidelines to some of the physical therapy modalities and procedures utilized in the
treatment of patients.
230.2 - Practice of Occupational Therapy
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)
A. General
Occupational therapy services are those services provided within the scope of practice of
occupational therapists and necessary for the diagnosis and treatment of impairments,
functional disabilities or changes in physical function and health status. (See Pub. 100-
03, the Medicare National Coverage Determinations Manual, for specific conditions or
services.)
Occupational therapy is medically prescribed treatment concerned with improving or
restoring functions which have been impaired by illness or injury or, where function has
been permanently lost or reduced by illness or injury, to improve the individual’s ability
to perform those tasks required for independent functioning. Such therapy may involve:
• The evaluation, and reevaluation as required, of a patient’s level of function by
administering diagnostic and prognostic tests;
• The selection and teaching of task-oriented therapeutic activities designed to
restore physical function; e.g., use of woodworking activities on an inclined table
to restore shoulder, elbow, and wrist range of motion lost as a result of burns;
• The planning, implementing, and supervising of individualized therapeutic
activity programs as part of an overall “active treatment” program for a patient
with a diagnosed psychiatric illness; e.g., the use of sewing activities which
require following a pattern to reduce confusion and restore reality orientation in a
schizophrenic patient;
• The planning and implementing of therapeutic tasks and activities to restore
sensory-integrative function; e.g., providing motor and tactile activities to
increase sensory input and improve response for a stroke patient with functional
loss resulting in a distorted body image;
• The teaching of compensatory technique to improve the level of independence in
the activities of daily living or adapt to an evolving deterioration in health and
function, for example:
o Teaching a patient who has lost the use of an arm how to pare potatoes
and chop vegetables with one hand;
o Teaching an upper extremity amputee how to functionally utilize a
prosthesis;
o Teaching a stroke patient new techniques to enable the patient to perform
feeding, dressing, and other activities as independently as possible; or
o Teaching a patient with a hip fracture/hip replacement techniques of
standing tolerance and balance to enable the patient to perform such
functional activities as dressing and homemaking tasks.
• The designing, fabricating, and fitting of orthotics and self-help devices; e.g.,
making a hand splint for a patient with rheumatoid arthritis to maintain the
hand in a functional position or constructing a device which would enable an
individual to hold a utensil and feed independently; or
• Vocational and prevocational assessment and training, subject to the
limitations specified in item B below.
Only a qualified occupational therapist has the knowledge, training, and experience
required to evaluate and, as necessary, reevaluate a patient’s level of function, determine
whether an occupational therapy program could reasonably be expected to improve,
restore, or compensate for lost function, recommend to the physician/NPP a plan of
treatment, where appropriate.
B. Qualified Occupational Therapist Defined
Reference: 42CFR484.4
The new personnel qualifications for occupational therapists (OT) were discussed in the
2008 Physician Fee Schedule. See the Federal Register of November 27, 2007, for the
full text. See also the correction notice for this rule, published in the Federal Register on
January 15, 2008.
The regulation provides that a qualified OT is an individual who is licensed, if licensure
applies, or otherwise regulated, if applicable, as an OT by the state in which practicing,
and graduated from an accredited education program for OTs, and is eligible to take or
has passed the examination for OTs administered by the National Board for Certification
in Occupational Therapy, Inc. (NBCOT). The phrase, “by the state in which practicing”
includes any authorization to practice provided by the same state in which the service is
provided, including temporary licensure, regardless of the location of the entity billing
the services. The education program for U.S. trained OTs is accredited by the
Accreditation Council for Occupational Therapy Education (ACOTE). The requirements
above apply to all OTs effective January 1, 2010, if they have not met any of the
following requirements prior to January 1, 2010.
The OTs may also qualify if on or before December 31, 2009:
• they are licensed or otherwise regulated as an OT in the state in which practicing
(regardless of the qualifications they met to obtain that licensure or regulation);
or
• when licensure or other regulation does not apply, OTs have graduated from an
OT education program accredited by ACOTE and are eligible to take, or have
successfully completed the NBCOT examination for OTs.
Also, those OTs who met the Medicare requirements for OTs that were in 42CFR484.4
prior to January 1, 2008, qualify to provide OT services for Medicare beneficiaries if:
• on or before January 1, 2008, they graduated an OT program approved jointly by
the American Medical Association and the AOTA, or
• they are eligible for the National Registration Examination of AOTA or the
National Board for Certification in OT.
Also, they qualify who on or before December 31, 1977, had 2 years of appropriate
experience as an occupational therapist, and had achieved a satisfactory grade on a
proficiency examination conducted, approved, or sponsored by the U.S. Public Health
Service.
Those educated outside the U.S. may meet the same qualifications for domestic trained
OTs. For example, they qualify if they were licensed or otherwise regulated by the state
in which practicing on or before December 31, 2009. Or they are qualified if they:
• graduated from an OT education program accredited as substantially equivalent to
a U.S. OT education program by ACOTE, the World Federation of Occupational
Therapists, or a credentialing body approved by AOTA; and
• passed the NBCOT examination for OT; and
• Effective January 1, 2010, are licensed or otherwise regulated, if applicable as an
OT by the state in which practicing.
For outpatient OT services that are provided incident to the services of physicians/NPPs,
the requirement for OT licensure does not apply; all other personnel qualifications do
apply. The qualified personnel providing OT services incident to the services of a
physician/NPP must be trained in an accredited OT curriculum. For example, a person
who, on or before December 31, 2009, graduated from an OT curriculum accredited by
ACOTE and is eligible to take or has successfully completed the entry-level certification
examination for OTs developed and administered by NBCOT, could provide Medicare
outpatient OT services incident to the services of a physician/NPP if the physician
assumes responsibility for the services according to the incident to policies. On or after
January 1, 2010, although licensure does not apply, both education and examination
requirements that are effective January 1, 2010, apply to qualified personnel who provide
OT services incident to the services of a physician/NPP.
C. Services of Occupational Therapy Support Personnel
Reference: 42CFR 484.4
The new personnel qualifications for occupational therapy assistants were discussed in
the 2008 Physician Fee Schedule. See the Federal Register of November 27, 2007, for
the full text. See also the correction notice for this rule, published in the Federal Register
on January 15, 2008.
The regulation provides that an occupational therapy assistant is a person who is licensed,
unless licensure does not apply, or otherwise regulated, if applicable, as an OTA by the
state in which practicing, and graduated from an OTA education program accredited by
ACOTE and is eligible to take or has successfully completed the NBCOT examination
for OTAs. The phrase, “by the state in which practicing” includes any authorization to
practice provided by the same state in which the service is provided, including temporary
licensure, regardless of the location of the entity billing the services.
If the requirements above are not met, an OTA may qualify if, on or before December 31,
2009, the OTA is licensed or otherwise regulated as an OTA, if applicable, by the state in
which practicing, or meets any qualifications defined by the state in which practicing.
Or, where licensure or other state regulation does not apply, OTAs may qualify if they
have, on or before December 31, 2009:
• completed certification requirements to practice as an OTA established by a
credentialing organization approved by AOTA; and
• after January 1, 2010, they have also completed an education program accredited
by ACOTE and passed the NBCOT examination for OTAs.
OTAs who qualified under the policies in effect prior to January 1, 2008, continue to
qualify to provide OT directed and supervised OTA services to Medicare beneficiaries.
Therefore, OTAs qualify who after December 31, 1977, and on or before December 31,
2007:
• completed certification requirements to practice as an OTA established by a
credentialing organization approved by AOTA; or
• completed the requirements to practice as an OTA applicable in the state in which
practicing.
Those OTAs who were educated outside the U.S. may meet the same requirements as
domestically trained OTAs. Or, if educated outside the U.S. on or after January 1, 2008,
they must have graduated from an OTA program accredited as substantially equivalent to
OTA entry level education in the U.S. by ACOTE, its successor organization, or the
World Federation of Occupational Therapists or a credentialing body approved by
AOTA. In addition, they must have passed an exam for OTAs administered by NBCOT.
Services. The services of OTAs used when providing covered therapy benefits are
included as part of the covered service. These services are billed by the supervising
occupational therapist. OTAs may not provide evaluative or assessment services, make
clinical judgments or decisions; develop, manage, or furnish skilled maintenance program
services; or take responsibility for the service. They act at the direction and under the
supervision of the treating occupational therapist and in accordance with state laws.
An occupational therapist must supervise OTAs. The level and frequency of supervision
differs by setting (and by state or local law). General supervision is required for OTAs in
all settings except private practice (which requires direct supervision) unless state
practice requirements are more stringent, in which case state or local requirements must
be followed. See specific settings for details. For example, in clinics, rehabilitation
agencies, and public health agencies, 42CFR485.713 indicates that when an OTA
provides services, either on or off the organization’s premises, those services are
supervised by a qualified occupational therapist who makes an onsite supervisory visit at
least once every 30 days or more frequently if required by state or local laws or
regulation.
The services of an OTA shall not be billed as services incident to a physician/NPP’s
service, because they do not meet the qualifications of a therapist.
The cost of supplies (e.g., looms, ceramic tiles, or leather) used in furnishing covered
therapy care is included in the payment for the HCPCS codes billed by the occupational
therapist and are, therefore, not separately billable. Separate coverage and billing
provisions apply to items that meet the definition of brace in §130 of this manual.
Services provided by aides, even if under the supervision of a therapist, are not therapy
services in the outpatient setting and are not covered by Medicare. Although an aide may
help the therapist by providing unskilled services, those services that are unskilled are not
covered by Medicare and shall be denied as not reasonable and necessary if they are
billed as therapy services.
D. Application of Medicare Guidelines to Occupational Therapy Services
Occupational therapy may be required for a patient with a specific diagnosed psychiatric
illness. If such services are required, they are covered assuming the coverage criteria are
met. However, where an individual’s motivational needs are not related to a specific
diagnosed psychiatric illness, the meeting of such needs does not usually require an
individualized therapeutic program. Such needs can be met through general activity
programs or the efforts of other professional personnel involved in the care of the patient.
Patient motivation is an appropriate and inherent function of all health disciplines, which
is interwoven with other functions performed by such personnel for the patient.
Accordingly, since the special skills of an occupational therapist are not required, an
occupational therapy program for individuals who do not have a specific diagnosed
psychiatric illness is not to be considered reasonable and necessary for the treatment of an
illness or injury. Services furnished under such a program are not covered.
Occupational therapy may include vocational and prevocational assessment and training.
When services provided by an occupational therapist are related solely to specific
employment opportunities, work skills, or work settings, they are not reasonable or
necessary for the diagnosis or treatment of an illness or injury and are not covered.
However, A/B MACs (A), (B), and (HHH) exercise care in applying this exclusion,
because the assessment of level of function and the teaching of compensatory techniques
to improve the level of function, especially in activities of daily living, are services which
occupational therapists provide for both vocational and nonvocational purposes. For
example, an assessment of sitting and standing tolerance might be nonvocational for a
mother of young children or a retired individual living alone, but could also be a
vocational test for a sales clerk. Training an amputee in the use of prosthesis for
telephoning is necessary for everyday activities as well as for employment purposes.
Major changes in life style may be mandatory for an individual with a substantial
disability. The techniques of adjustment cannot be considered exclusively vocational or
nonvocational.
230.3 - Practice of Speech-Language Pathology
(Rev. 106, Issued: 04-24-09, Effective: 07-01-09, Implementation: 07-06-09)
A. General
Speech-language pathology services are those services provided within the scope of
practice of speech-language pathologists and necessary for the diagnosis and treatment of
speech and language disorders, which result in communication disabilities and for the
diagnosis and treatment of swallowing disorders (dysphagia), regardless of the presence
of a communication disability. (See Pub. 100-03, chapter 1, §170.3) See section 230.4
of this chapter for benefit policies on speech-language pathologists in private practice
(SLPP). See Pub. 100-08, Medicare Program Integrity Manual, chapter 10, section
12.4.14 for policy on enrollment in an SLPP.
B. Qualified Speech-Language Pathologist Defined
A qualified speech-language pathologist for program coverage purposes meets one of the
following requirements:
• The education and experience requirements for a Certificate of Clinical
Competence in (speech-language pathology) granted by the American Speech-
Language Hearing Association; or
• Meets the educational requirements for certification and is in the process of
accumulating the supervised experience required for certification.
For outpatient speech-language pathology services that are provided incident to the
services of physicians/NPPs, the requirement for speech-language pathology licensure
does not apply; all other personnel qualifications do apply. Therefore, qualified
personnel providing speech-language pathology services incident to the services of a
physician/NPP must meet the above qualifications.
C. Services of Speech-Language Pathology Support Personnel
Services of speech-language pathology assistants are not recognized for Medicare
coverage. Services provided by speech-language pathology assistants, even if they are
licensed to provide services in their states, will be considered unskilled services and
denied as not reasonable and necessary if they are billed as therapy services.
Services provided by aides, even if under the supervision of a therapist, are not therapy
services and are not covered by Medicare. Although an aide may help the therapist by
providing unskilled services, those services are not covered by Medicare and shall be
denied as not reasonable and necessary if they are billed as therapy services.
D. Application of Medicare Guidelines to Speech-Language Pathology Services
1. Evaluation Services
Speech-language pathology evaluation services are covered if they are reasonable and
necessary and not excluded as routine screening by §1862(a)(7) of the Act. The speech-
language pathologist employs a variety of formal and informal speech, language, and
dysphagia assessment tests to ascertain the type, causal factor(s), and severity of the
speech and language or swallowing disorders. Reevaluation of patients for whom speech,
language and swallowing were previously contraindicated is covered only if the patient
exhibits a change in medical condition. However, monthly reevaluations; e.g., a Western
Aphasia Battery, for a patient undergoing a rehabilitative speech-language pathology
program, are considered a part of the treatment session and shall not be covered as a
separate evaluation for billing purposes. Although hearing screening by the speech-
language pathologist may be part of an evaluation, it is not billable as a separate service.
2. Therapeutic Services
The following are examples of common medical disorders and resulting communication
deficits, which may necessitate active rehabilitative therapy. This list is not all-inclusive:
Cerebrovascular disease such as cerebral vascular accidents presenting with
dysphagia, aphasia/dysphasia, apraxia, and dysarthria;
Neurological disease such as Parkinsonism or Multiple Sclerosis with dysarthria,
dysphagia, inadequate respiratory volume/control, or voice disorder; or
Laryngeal carcinoma requiring laryngectomy resulting in aphonia.
3. Impairments of the Auditory System
The terms, aural rehabilitation, auditory rehabilitation, auditory processing, lipreading
and speech reading are among the terms used to describe covered services related to
perception and comprehension of sound through the auditory system. See Pub. 100-04,
chapter 12, section 30.3 for billing instructions. For example:
° Auditory processing evaluation and treatment may be covered and medically
necessary. Examples include but are not limited to services for certain
neurological impairments or the absence of natural auditory stimulation that
results in impaired ability to process sound. Certain auditory processing
disorders require diagnostic audiological tests in addition to speech-language
pathology evaluation and treatment.
° Evaluation and treatment for disorders of the auditory system may be covered
and medically necessary, for example, when it has been determined by a speech-
language pathologist in collaboration with an audiologist that the hearing
impaired beneficiary’s current amplification options (hearing aid, other
amplification device or cochlear implant) will not sufficiently meet the patient’s
functional communication needs. Audiologists and speech-language pathologists
both evaluate beneficiaries for disorders of the auditory system using different
skills and techniques, but only speech-language pathologists may provide
treatment.
Assessment for the need for rehabilitation of the auditory system (but not the vestibular
system) may be done by a speech language pathologist. Examples include but are not
limited to: evaluation of comprehension and production of language in oral, signed or
written modalities, speech and voice production, listening skills, speech reading,
communications strategies, and the impact of the hearing loss on the patient/client and
family.
Examples of rehabilitation include but are not limited to treatment that focuses on
comprehension, and production of language in oral, signed or written modalities; speech
and voice production, auditory training, speech reading, multimodal (e.g., visual,
auditory-visual, and tactile) training, communication strategies, education and
counseling. In determining the necessity for treatment, the beneficiary’s performance in
both clinical and natural environment should be considered.
4. Dysphagia
Dysphagia, or difficulty in swallowing, can cause food to enter the airway, resulting in
coughing, choking, pulmonary problems, aspiration or inadequate nutrition and hydration
with resultant weight loss, failure to thrive, pneumonia and death. It is most often due to
complex neurological and/or structural impairments including head and neck trauma,
cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer,
dementias, and encephalopathies. For these reasons, it is important that only qualified
professionals with specific training and experience in this disorder provide evaluation and
treatment.
The speech-language pathologist performs clinical and instrumental assessments and
analyzes and integrates the diagnostic information to determine candidacy for
intervention as well as appropriate compensations and rehabilitative therapy techniques.
The equipment that is used in the examination may be fixed, mobile or portable.
Professional guidelines recommend that the service be provided in a team setting with a
physician/NPP who provides supervision of the radiological examination and
interpretation of medical conditions revealed in it.
Swallowing assessment and rehabilitation are highly specialized services. The
professional rendering care must have education, experience and demonstrated
competencies. Competencies include but are not limited to: identifying abnormal upper
aerodigestive tract structure and function; conducting an oral, pharyngeal, laryngeal and
respiratory function examination as it relates to the functional assessment of swallowing;
recommending methods of oral intake and risk precautions; and developing a treatment
plan employing appropriate compensations and therapy techniques.
230.4 - Services Furnished by a Therapist in Private Practice (TPP)
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)
A. General
See section 220 of this chapter for definitions. Therapist refers only to a qualified
physical therapist, occupational therapist or speech-language pathologist. TPP refers to
therapists in private practice (qualified physical therapists, occupational therapists and
speech-language pathologists).
In order to qualify to bill Medicare directly as a therapist, each individual must be
enrolled as a private practitioner and employed in one of the following practice types: an
unincorporated solo practice, unincorporated partnership, unincorporated group practice,
physician/NPP group or groups that are not professional corporations, if allowed by state
and local law. Physician/NPP group practices may employ TPP if state and local law
permits this employee relationship.
For purposes of this provision, a physician/NPP group practice is defined as one or more
physicians/NPPs enrolled with Medicare who may bill as one entity. For further details
on issues concerning enrollment, see the provider enrollment Web site at
www.cms.hhs.gov/MedicareProviderSupEnroll and Pub. 100-08, Medicare Program
Integrity Manual, chapter15, section 15.4.4.9.
Private practice also includes therapists who are practicing therapy as employees of
another supplier, of a professional corporation or other incorporated therapy practice.
Private practice does not include individuals when they are working as employees of an
institutional provider.
Services should be furnished in the therapist’s or group’s office or in the patient’s home.
The office is defined as the location(s) where the practice is operated, in the state(s)
where the therapist (and practice, if applicable) is legally authorized to furnish services,
during the hours that the therapist engages in the practice at that location. If services are
furnished in a private practice office space, that space shall be owned, leased, or rented
by the practice and used for the exclusive purpose of operating the practice. For
descriptions of aquatic therapy in a community center pool see section 220C of this
chapter.
Therapists in private practice must be approved as meeting certain requirements, but do
not execute a formal provider agreement with the Secretary.
If therapists who have their own Medicare National Provider Identifier (NPI) are
employed by therapist groups, physician/NPP groups, or groups that are not professional
organizations, the requirement that therapy space be owned, leased, or rented may be
satisfied by the group that employs the therapist. Each therapist employed by a group
should enroll as a TPP.
When therapists with a Medicare NPI provide services in the physician’s/NPP’s office in
which they are employed, and bill using their NPI for each therapy service, then the
direct supervision requirement for enrolled staff apply.
When the therapist who has a Medicare NPI is employed in a physician’s/NPP’s office
the services are ordinarily billed as services of the therapist, with the therapist identified
on the claim as the supplier of services. However, services of the therapist who has a
Medicare NPI may also be billed by the physician/NPP as services incident to the
physician’s/NPP’s service. (See §230.5 for rules related to therapy services incident to a
physician.) In that case, the physician/NPP is the supplier of service, the NPI of the
supervising physician/NPP is reported on the claim with the service and all the rules for
both therapy services and incident to services (§230.5) must be followed.
B. Private Practice Defined
Reference: Federal Register November, 1998, pages 58863-58869; 42CFR 410.38(b),
42CFR410.59, 42CFR410.60, 42CFR410.62
The contractor considers a therapist to be in private practice if the therapist maintains
office space at his or her own expense and furnishes services only in that space or the
patient’s home. Or, a therapist is employed by another supplier and furnishes services in
facilities provided at the expense of that supplier.
The therapist need not be in full-time private practice but must be engaged in private
practice on a regular basis; i.e., the therapist is recognized as a private practitioner and for
that purpose has access to the necessary equipment to provide an adequate program of
therapy.
The therapy services must be provided either by or under the direct supervision of the
TPP. Each TPP should be enrolled as a Medicare provider. If a therapist is not enrolled,
the services of that therapist must be directly supervised by an enrolled therapist. Direct
supervision requires that the supervising private practice therapist be present in the office
suite at the time the service is performed. These direct supervision requirements apply
only in the private practice setting and only for therapists and their assistants. In other
outpatient settings, supervision rules differ. The services of support personnel must be
included in the therapist’s bill. The supporting personnel, including other therapists,
must be W-2 or 1099 employees of the TPP or other qualified employer.
Coverage of outpatient therapy under Part B includes the services of a qualified TPP
when furnished in the therapist’s office or the beneficiary’s home. For this purpose,
“home” includes an institution that is used as a home, but not a hospital, CAH or SNF,
(Federal Register Nov. 2, 1998, pg 58869).
C. Assignment
Reference: Nov. 2, 1998 Federal Register, pg. 58863
See also Pub. 100-04 chapter 1, §30.2.
When physicians, NPPs, or TPPs obtain provider numbers, they have the option of
accepting assignment (participating) or not accepting assignment (nonparticipating). In
contrast, providers, such as outpatient hospitals, SNFs, rehabilitation agencies, and
CORFs, do not have the option. For these providers, assignment is mandatory.
If physicians/NPPs, or TPPs accept assignment (are participating), they must accept the
Medicare Physician Fee Schedule amount as payment. Medicare pays 80% and the
patient is responsible for 20%. In contrast, if they do not accept assignment, Medicare
will only pay 95% of the fee schedule amount. However, when these services are not
furnished on an assignment-related basis, the limiting charge applies. (See
§1848(g)(2)(c) of the Act.)
NOTE: Services furnished by a therapist in the therapist’s office under arrangements
with hospitals in rural communities and public health agencies (or services provided in
the beneficiary’s home under arrangements with a provider of outpatient physical or
occupational therapy services) are not covered under this provision. See section 230.6.
230.5 - Physical Therapy, Occupational Therapy and Speech-Language
Pathology Services Provided Incident to the Services of Physicians and
Non-Physician Practitioners (NPP)
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)
References: §1861(s)(2)(A) of the Act
42 CFR 410.10(b)
42 CFR 410.26
Pub. 100-02, ch. 15, §60.
The Benefit. Therapy services have their own benefit under §1861 of the Social Security
Act and shall be covered when provided according to the standards and conditions of the
benefit described in Medicare manuals. The statute 1862(a)(20) requires that payment be
made for a therapy service billed by a physician/NPP only if the service meets the
standards and conditions--other than licensing--that would apply to a therapist. (For
example, see coverage requirements in Pub. 100-08, chapter 13, §13.5.1(C), Pub. 100-04,
chapter 5, and also the requirements of this chapter, §220 and §230.
Incident to a Therapist. There is no coverage for services provided incident to the
services of a therapist. Although PTAs and OTAs work under the supervision of a
therapist and their services may be billed by the therapist, their services are covered
under the benefit for therapy services and not by the benefit for services incident to a
physician/NPP. The services furnished by PTAs and OTAs are not incident to the
therapist’s service.
Qualifications of Auxiliary Personnel. Therapy services appropriately billed incident to a
physician’s/NPP’s service shall be subject to the same requirements as therapy services
that would be furnished by a physical therapist, occupational therapist or speech-language
pathologist in any other outpatient setting with one exception. When therapy services are
performed incident to a physician’s/NPP’s service, the qualified personnel who perform
the service do not need to have a license to practice therapy, unless it is required by state
law. The qualified personnel must meet all the other requirements except licensure.
Qualifications for therapists are found in 42CFR484.4 and in section 230.1, 230.2, and
230.3 of this chapter. In effect, these rules require that the person who furnishes the
service to the patient must, at least, be a graduate of a program of training for one of the
therapy services as described above. Regardless of any state licensing that allows other
health professionals to provide therapy services, Medicare is authorized to pay only for
services provided by those trained specifically in physical therapy, occupational therapy
or speech-language pathology. That means that the services of athletic trainers, massage
therapists, recreation therapists, kinesiotherapists, low vision specialists or any other
profession may not be billed as therapy services.
The services of PTAs and OTAs also may not be billed incident to a physician’s/NPP’s
service. However, if a PT and PTA (or an OT and OTA) are both employed in a
physician’s office, the services of the PTA, when directly supervised by the PT or the
services of the OTA, when directly supervised by the OT may be billed by the physician
group as PT or OT services using the PIN/NPI of the enrolled PT (or OT). (See Section
230.4 for private practice rules on billing services performed in a physician’s office.) If
the PT or OT is not enrolled, Medicare shall not pay for the services of a PTA or OTA
billed incident to the physician’s service, because they do not meet the qualification
standards in 42CFR484.4.
Therapy services provided and billed incident to the services of a physician/NPP also
must meet all incident-to requirements in §60 of this chapter. Where the policies have
different requirements, the more stringent requirement shall be met.
For example, when therapy services are billed as incident to a physician/NPP services,
the requirement for direct supervision by the physician/NPP and other incident to
requirements must be met, even though the service is provided by a licensed therapist
who may perform the services unsupervised in other settings.
The mandatory assignment provision does not apply to therapy services furnished by a
physician/NPP or "incident to" a physician's/NPP’s service. However, when these
services are not furnished on an assignment-related basis; the limiting charge applies.
For emphasis, following are some of the standards that apply to therapy services billed
incident-to the services of a physician/NPP in the physician’s/NPP’s office or the
beneficiary’s residence.
A. Therapy services provided to the beneficiary must be covered and payable
outpatient rehabilitation services as described, for example, in this section as well
as Pub. 100-08, chapter 13, §13.5.1.
B. Therapy services must be provided by, or under the direct supervision of a
physician (a doctor of medicine or osteopathy; a doctor of podiatry or a doctor of
optometry when treating patients within the state scope of practice in the state in
which the services are provided) or NPP who is legally authorized to practice
therapy services by the state in which he or she performs such function or action.
Direct supervision requirements are the same as in 42CFR410.32(b)(3). The
supervisor must be present in the office suite and immediately available to furnish
assistance and direction throughout the performance of the procedure. It does not
mean that the physician/NPP must be present in the same room in the office
where the service is performed.
C. The services must be of a level of complexity that require that they be performed
by a therapist or under the direct supervision of the therapist, physician/NPP who
is licensed to perform them. Services that do not require the performance or
supervision of the therapist, physician/NPP, are not considered reasonable or
necessary therapy services even if they are performed or supervised by a
physician/NPP or other qualified professional.
D. Services must be furnished under a plan of treatment as in §220.1.2 of this
chapter. The services provided must relate directly to the physician/NPP service
to which it is incident.
230.6 - Therapy Services Furnished Under Arrangements With
Providers and Clinics
(Rev. 36, Issued: 06-24-05, Effective: 06-06-05, Implementation: 06-06-05)
References: See also Pub. 100-01, chapter 5, §10.3.
A. General
For rules regarding services provided under arrangement, see Pub. 100-01, chapter 5,
§10.3.
A provider may have others furnish outpatient therapy (physical therapy, occupational
therapy, or speech-language pathology) services through arrangements under which
receipt of payment by the provider for the services discharges the liability of the
beneficiary or any other person to pay for the service.
However, it is not intended that the provider merely serve as a billing mechanism for the
other party. For such services to be covered the provider must assume professional
responsibility for the services.
The provider’s professional supervision over the services requires application of many of
the same controls that are applied to services furnished by salaried employees. The
provider must:
• Accept the patient for treatment in accordance with its admission policies;
• Maintain a complete and timely clinical record on the patient which includes
diagnosis, medical history, orders, and progress notes relating to all services
received;
• Maintain liaison with the attending physician/NPP with regard to the progress of
the patient and to assure that the required plan of treatment is periodically
reviewed by the physician/NPP;
• Secure from the physician/NPP the required certifications and recertifications;
and
• Ensure that the medical necessity of such service is reviewed on a sample basis by
the agency’s staff or an outside review group.
In addition, when a provider provides outpatient services under an arrangement with
others, such services must be furnished in accordance with the terms of a written contract,
which provides for retention by the provider of responsibility for and control and
supervision of such services. The terms of the contract should include at least the
following:
• Provide that the therapy services are to be furnished in accordance with the
plan of care established according to Medicare policies for therapy plans of
care in section 220.1.2 of this chapter;
• Specify the geographical areas in which the services are to be furnished;
• Provide that contracted personnel and services meet the same requirements as
those which would be applicable if the personnel and services were furnished
directly by the provider;
• Provide that the therapist will participate in conferences required to coordinate
the care of an individual patient;
• Provide for the preparation of treatment records, with progress notes and
observations, and for the prompt incorporation of such into the clinical records
of the clinic;
• Specify the financial arrangements. The contracting organization or
individual may not bill the patient or the health insurance program; and
• Specify the period of time the contract is to be in effect and the manner of
termination or renewal.
B. Special Rules for Hospitals
• A hospital may bill Medicare for outpatient therapy (physical therapy,
occupational therapy, or speech-language pathology) services that it furnishes
to its outpatients either directly or under arrangements in the hospital's
outpatient department. If a hospital furnishes medically necessary therapy
services in its outpatient department to individuals who are registered as its
outpatients, those services must be billed directly by the hospital using bill
type 13X or 85X for critical access hospitals. Note that services provided to
residents of a Medicare-certified SNF may not be billed by the hospital as
services to its outpatients.
• When a hospital sends its therapists to the home of an individual who is
registered as an outpatient of the hospital but who is unable, for medical
reasons, to come to the hospital to receive medically necessary therapy
services, the services must meet the requirements applicable to outpatient
hospital therapy services, as set forth in the regulations and applicable
Medicare manuals. The hospital may bill for those services directly using bill
type 13X or 85X for critical access hospitals.
• If a hospital sends its therapists to provide therapy services to individuals who
are registered as its outpatients and who are residing in the non-certified part
of a SNF, or in another residential setting (e.g., a group home, assisted living
facility or domiciliary care home), the hospital may bill for the services as
hospital outpatient services if the services meet the requirements applicable to
outpatient hospital therapy services, as set forth in the regulations and
applicable Medicare manuals.
• A hospital may make an arrangement with another entity such as an
Outpatient Rehab Facility (Rehabilitation Agency) or a private practice, to
provide therapy services to individuals who are registered as outpatients of the
hospital. These services must meet the requirements applicable to services
furnished under arrangements and the requirements applicable to the
outpatient hospital therapy services as set forth in the regulations and
applicable Medicare manuals. The hospital uses bill type 13X or 85X for
critical access hospitals to bill for the services that another entity furnishes
under arrangement to its outpatients.
• Where the provider is a public health agency or a hospital in a rural
community, it may enter into arrangements to have outpatient physical
therapy services furnished in the private office of a qualified physical therapist
if the agency or hospital does not have the capacity to provide on its premises
all of the modalities of treatment, tests, and measurements that are included in
an adequate outpatient physical therapy program and the services and
modalities which the public health agency or hospital cannot provide on its
premises are not available on an outpatient basis in another accessible
certified facility.
• In certain settings and under certain circumstances, hospitals may not bill
Medicare for therapy services as services of the hospital:
○ If a hospital sends its therapists to provide therapy services to patients of
another hospital, including a patient at an inpatient rehabilitation facility
or a long term care facility, the services must be furnished under
arrangements made with the hospital sending the therapists by the hospital
having the patients and billed as hospital services by the facility whose
patients are treated. These services would be subject to existing hospital
bundling rules and would be paid under the payment method applicable to
the hospital at which the individuals are patients.
○ A hospital may not send its therapists to provide therapy services to
individuals who are receiving services from an HHA under a home health
plan of care and bill for the therapy services as hospital outpatient
services. For patients under a home health plan of care, payment for
therapy services (unless provided by physicians/NPPs) is included or
bundled into Medicare’s episodic payment to the HHA, and those services
must be billed by the HHA under the HHA consolidated billing rules. For
patients receiving HHA services under an HHA plan of care, therapy
services must be furnished directly or under arrangements made by the
HHA, and only the HHA may bill for those services.
○ If a hospital sends its therapists to provide services under arrangements
made by a SNF to residents of the Medicare-certified part of a SNF, SNF
consolidated billing rules apply. For arrangements specific to SNF Part A,
see Pub. 100-04, chapter 6, §10.4. This means that therapy services
furnished to SNF residents in the Medicare-certified part of a SNF cannot
be billed by any entity other than the SNF. Therefore, a hospital may not
bill Medicare for PT/OT/SLP services furnished to residents of a
Medicare-certified part of a SNF by its therapists as services of the
hospital.
NOTE: If the SNF resident is in a covered Part A stay, the therapy services would be
included in the SNF’s global PPS per diem payment for the covered Part A stay itself. If
the resident is in a noncovered stay (Part A benefits exhausted, no prior qualifying
hospital stay, etc.), but remains in the Medicare-certified part of a SNF, the SNF would
submit the Part B therapy bill to its A/B MAC (A).
SNF Setting Applicable Rules
Medicare Part A or B Consolidated
Billing Rules
Apply?
Hospital
May Bill
For
Outpatient
Services?
Part A (Medicare Covered / PPS)
Resident in Medicare-certified
part of a SNF
Yes No
Medicare Part B Resident in
Medicare-certified part of a SNF
Yes No
Medicare Part B
Not a Resident in Medicare-
certified part of a SNF
No Yes
• A hospital may not send therapy staff to provide therapy services in non-
residential health care settings and bill for the services as if they were
provided at the hospital, even if the hospital owns the other facility or entity.
Examples of such non-residential settings include CORFs, rehabilitation
agencies, ORFs and offices of physicians/NPPs or other practitioners, such as
physical therapists. For example, services furnished to patients of a CORF
must be billed as CORF services and not as outpatient hospital services. Even
if a CORF contracts with a hospital to furnish services to CORF patients, the
hospital may not bill Medicare for the services as hospital outpatient services.
However, the CORF could have the hospital furnish services to its patients
under arrangements, in which case the CORF would bill for the services.
Psychiatric hospitals are treated the same as other hospitals for the purpose of therapy
billing.
231 - Pulmonary Rehabilitation (PR) Program Services Effective For
Dates of Service On Or After January 1, 2024
(Rev. 12497; Issued: 02-08-24; Effective: 01-01-24; Implementation: 03-12-24)
Pulmonary rehabilitation (PR) means a physician or nonphysician practitioner supervised
program for chronic obstructive pulmonary disease (COPD) and certain other chronic
respiratory diseases designed to optimize physical and social performance and autonomy.
Nonphysician practitioner means a physician assistant, nurse practitioner, or clinical
nurse specialist as those terms are defined in section 1861(aa)(5)(A) of the Social
Security Act (the Act).
Effective January 1, 2010, Medicare Part B pays for PR if specific criteria are met by the
Medicare beneficiary, the PR program itself, the setting in which it is administered, and
the physician administering the program, as outlined below.
Covered Conditions:
As specified in 42 CFR 410.47, Medicare Part B covers PR for beneficiaries:
• With moderate to very severe COPD (defined as GOLD classification II, III, and
IV), when referred by the physician treating the chronic respiratory disease;
• Who have had confirmed or suspected COVID-19 and experience persistent
symptoms that include respiratory dysfunction for at least four weeks (effective
January 1, 2022);
• Additional medical indications for coverage for PR program services may be
established through a national coverage determination (NCD).
PR must include all of the following components:
Physician-prescribed exercise. Physician-prescribed exercise means aerobic exercise
combined with other types of exercise (such as conditioning, breathing retraining, step,
and strengthening) as determined to be appropriate for individual patients by a physician.
Each PR session must include physician prescribed exercise.
Education or training. Education or training that is closely and clearly related to the
individual’s care and treatment which is tailored to the individual’s needs and assists in
achievement of goals toward independence in activities of daily living, adaptation to
limitations and improved quality of life. Education must include information on
respiratory problem management and, if appropriate, brief smoking cessation counseling.
Psychosocial assessment. Psychosocial assessment means an evaluation of an
individual’s mental and emotional functioning as it relates to the individual’s
rehabilitation or respiratory condition which includes an assessment of those aspects of
an individual’s family and home situation that affects the individual’s rehabilitation
treatment, and psychosocial evaluation of the individual’s response to and rate of
progress under the treatment plan.
Outcomes assessment. Outcomes assessment means an evaluation of progress as it relates
to the individual’s rehabilitation which includes the following: (i) Evaluations, based on
patient-centered outcomes, which must be measured by the physician or program staff at
the beginning and end of the program. Evaluations measured by program staff must be
considered by the physician in developing and/or reviewing individualized treatment
plans. (ii) Objective clinical measures of exercise performance and self-reported
measures of shortness of breath and behavior.
Individualized treatment plan. Individualized treatment plan means a written plan tailored
to each individual patient that includes all of the following: (i) A description of the
individual’s diagnosis. (ii) The type, amount, frequency, and duration of the items and
services furnished under the plan. (iii) The goals set for the individual under the plan. The
individualized treatment plan detailing how components are utilized for each patient,
must be established, reviewed, and signed by a physician every 30 days.
As specified at 42 CFR 410.47(e), the number of PR sessions are limited to a maximum
of 2 1-hour sessions per day for up to 36 sessions over up to 36 weeks with the option for
an additional 36 sessions over an extended period of time if approved by the Medicare
Administrative Contractor (MAC).
PR Settings:
Medicare Part B pays for PR in a physician’s office or a hospital outpatient setting. All
settings must have the following: (i) A physician or nonphysician practitioner
immediately available and accessible for medical consultations and emergencies at all
times when items and services are being furnished under the program. This provision is
satisfied if the physician or nonphysician practitioner meets the requirements for direct
supervision for physician office services, at 42 CFR 410.26, and for hospital outpatient
services at 42 CFR 410.27, and (ii) The necessary cardiopulmonary, emergency,
diagnostic, and therapeutic life-saving equipment accepted by the medical community as
medically necessary (for example, oxygen, cardiopulmonary resuscitation equipment, and
defibrillator) to treat chronic respiratory disease.
PR Medical Director Standards:
Medical director means the physician who oversees the PR program at a particular site.
The medical director is the physician responsible for a PR program and, in consultation
with staff, is involved in directing the progress of individuals in the program and must
possess all of the following: (1) Expertise in the management of individuals with
respiratory pathophysiology. (2) Cardiopulmonary training in basic life support or
advanced cardiac life support. (3) Be licensed to practice medicine in the State in which
the PR program is offered.
Supervising Practitioner Standards:
Supervising practitioner means a physician or nonphysician practitioner that is
immediately available and accessible for medical consultations and medical emergencies
at all times items and services are being furnished to individuals under PR programs.
Physicians or nonphysician practitioners acting as the supervising practitioner must
possess all of the following: (1) Expertise in the management of individuals with
respiratory pathophysiology. (2) Cardiopulmonary training in basic life support or
advanced cardiac life support.
(See Publication 100-04, Claims Processing Manual, chapter 32, section 140.4, for PR
claims processing, coding, and billing requirements.)
232 - Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation
(ICR) Services Effective For Dates of Service On Or After January 1,
2024
(Rev. 12497; Issued: 02-08-24; Effective: 01-01-24; Implementation: 03-12-24)
Cardiac rehabilitation (CR) means a physician or nonphysician practitioner supervised
program that furnishes physician prescribed exercise; cardiac risk factor modification,
including education, counseling, and behavioral intervention; psychosocial assessment;
and outcomes assessment. Intensive cardiac rehabilitation (ICR) program means a
physician or nonphysician practitioner supervised program that furnishes CR and has
shown, in peer-reviewed published research, that it improves patients’ cardiovascular
disease through specific outcome measurements described in 42 CFR 410.49(c).
Nonphysician practitioner means a physician assistant, nurse practitioner, or clinical
nurse specialist as those terms are defined in section 1861(aa)(5)(A) of the Social
Security Act (the Act).
Effective January 1, 2010, Medicare Part B pays for CR/ICR if specific criteria are met
by the Medicare beneficiary, the CR/ICR program itself, the setting in which it is
administered, and the physician administering the program, as outlined below.
Covered Conditions:
As specified in 42 CFR 410.49, Medicare Part B covers CR and ICR for beneficiaries
who have experienced one or more of the following:
• An acute myocardial infarction (MI) within the preceding 12 months;
• A coronary artery bypass surgery;
• Current stable angina pectoris;
• Heart valve repair or replacement;
• Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting;
• A heart or heart-lung transplant.
• Stable, chronic heart failure defined as patients with left ventricular ejection
fraction of 35% or less and New York Heart Association (NYHA) class II to IV
symptoms despite being on optimal heart failure therapy for at least 6 weeks, on
or after February 18, 2014, for CR and on or after February 9, 2018, for ICR; or
• Other cardiac conditions as specified through a national coverage determination
(NCD). The NCD process may also be used to specify non-coverage of a cardiac
condition for ICR if coverage is not supported by clinical evidence.
CR and ICR must include all of the following components:
Physician-prescribed exercise. Physician-prescribed exercise means aerobic exercise
combined with other types of exercise (such as strengthening and stretching) as
determined to be appropriate for individual patients by a physician each day CR/ICR
items and services are furnished.
Cardiac risk factor modification. Cardiac risk factor modification, including education,
counseling, and behavioral intervention, tailored to the individual’s needs.
Psychosocial assessment. Psychosocial assessment means an evaluation of an
individual’s mental and emotional functioning as it relates to the individual’s
rehabilitation which includes an assessment of those aspects of an individual’s family and
home situation that affects the individual’s rehabilitation treatment, and psychosocial
evaluation of the individual’s response to and rate of progress under the treatment plan.
Outcomes assessment. Outcomes assessment means an evaluation of progress as it relates
to the individual’s rehabilitation which includes all of the following: (i) Evaluations,
based on patient-centered outcomes, which must be measured by the physician or
program staff at the beginning and end of the program. Evaluations measured by program
staff must be considered by the physician in developing and/or reviewing individualized
treatment plans. (ii) Objective clinical measures of exercise performance and self-
reported measures of exertion and behavior.
Individualized treatment plan. Individualized treatment plan means a written plan tailored
to each individual patient that includes all of the following: (i) A description of the
individual’s diagnosis. (ii) The type, amount, frequency, and duration of the items and
services furnished under the plan. (iii) The goals set for the individual under the plan. The
individualized treatment plan detailing how components are utilized for each patient,
must be established, reviewed, and signed by a physician every 30 days.
As specified at 42 CFR 410.49(f)(1), the number of CR sessions are limited to a
maximum of 2 1-hour sessions per day for up to 36 sessions over up to 36 weeks with the
option for an additional 36 sessions over an extended period of time if approved by the
Medicare Administrative Contractor (MAC).
As specified at 42 CFR 410.49(f)(2), ICR sessions are limited to 72 1-hour sessions (as
defined in section 1848(b)(5) of the Act), up to 6 sessions per day, over a period of up to
18 weeks.
CR and ICR Settings:
Medicare Part B pays for CR and ICR in a physician’s office or a hospital outpatient
setting. All settings must have a physician or nonphysician practitioner immediately
available and accessible for medical consultations and emergencies at all times when
items and services are being furnished under the program. This provision is satisfied if
the physician or nonphysician practitioner meets the requirements for direct supervision
for physician office services, at 42 CFR 410.26, and for hospital outpatient services at 42
CFR 410.27.
Standards for an ICR Program:
To be approved as an ICR program, a program must demonstrate through peer-reviewed,
published research that it has accomplished one or more of the following for its patients:
(i) Positively affected the progression of coronary heart disease. (ii) Reduced the need for
coronary bypass surgery. (iii) Reduced the need for percutaneous coronary interventions.
An ICR program must also demonstrate through peer-reviewed published research that it
accomplished a statistically significant reduction in 5 or more of the following measures
for patients from their levels before CR services to after CR services: (i) Low density
lipoprotein. (ii) Triglycerides. (iii) Body mass index. (iv) Systolic blood pressure. (v)
Diastolic blood pressure. (vi) The need for cholesterol, blood pressure, and diabetes
medications.
A list of approved ICR programs, identified through the NCD process, will be listed in
the Federal Register and is available on the CMS website at
https://www.cms.gov/Medicare/Medicare-
GeneralInformation/MedicareApprovedFacilitie/ICR. All prospective ICR sites must
apply to enroll as an ICR program site using the designated forms as specified at 42 CFR
424.510, and report specialty code 31 to be identified as an enrolled ICR supplier. For
purposes of appealing an adverse determination concerning site approval, an ICR site is
considered a supplier (or prospective supplier) as defined in 42 CFR 498.2.
CR and ICR Medical Director Standards:
Medical director means the physician who oversees the CR or ICR program at a
particular site. The medical director is the physician responsible for a CR or ICR program
and, in consultation with staff, is involved in directing the progress of individuals in the
program and must possess all of the following: (1) Expertise in the management of
individuals with cardiac pathophysiology. (2) Cardiopulmonary training in basic life
support or advanced cardiac life support. (3) Be licensed to practice medicine in the State
in which the CR or ICR program is offered.
Supervising Practitioner Standards:
Supervising practitioner means a physician or nonphysician practitioner that is
immediately available and accessible for medical consultations and medical emergencies
at all times items and services are being furnished to individuals under CR and ICR
programs. Physicians or nonphysician practitioners acting as the supervising practitioner
must possess all of the following: (1) Expertise in the management of individuals with
cardiac pathophysiology. (2) Cardiopulmonary training in basic life support or advanced
cardiac life support.
(See Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part
1, section 20.10.1, Pub. 100-04, Medicare Claims Processing Manual, Chapter 32, section
140, Pub. 100-08, Medicare Program Integrity Manual, Chapter 10, section 10.2.2.5, for
CR and ICR claims processing, coding, and billing requirements.)
240 - Chiropractic Services - General
(Rev. 1, 10-01-03)
B3-2250, B3-4118
The term “physician” under Part B includes a chiropractor who meets the specified
qualifying requirements set forth in §30.5 but only for treatment by means of manual
manipulation of the spine to correct a subluxation.
Effective for claims with dates of services on or after January 1, 2000, an x-ray is not
required to demonstrate the subluxation.
Implementation of the chiropractic benefit requires an appreciation of the differences
between chiropractic theory and experience and traditional medicine due to fundamental
differences regarding etiology and theories of the pathogenesis of disease. Judgments
about the reasonableness of chiropractic treatment must be based on the application of
chiropractic principles. So that Medicare beneficiaries receive equitable adjudication of
claims based on such principles and are not deprived of the benefits intended by the law,
A/B MACs (B) may use chiropractic consultation in A/B MAC (B) review of Medicare
chiropractic claims.
Payment is based on the physician fee schedule and made to the beneficiary or, on
assignment, to the chiropractor.
A. Verification of Chiropractor’s Qualifications
A/B MACs (B) must establish a reference file of chiropractors eligible for payment as
physicians under the criteria in §30.1. They pay only chiropractors on file. Information
needed to establish such files is furnished by the CMS RO.
The RO is notified by the appropriate State agency which chiropractors are licensed and
whether each meets the national uniform standards.
240.1 - Coverage of Chiropractic Services
(Rev. 1, 10-01-03)
B3-2251
240.1.1 - Manual Manipulation
(Rev. 1, 10-01-03)
B3-2251.1
Coverage of chiropractic service is specifically limited to treatment by means of manual
manipulation, i.e., by use of the hands. Additionally, manual devices (i.e., those that are
hand-held with the thrust of the force of the device being controlled manually) may be
used by chiropractors in performing manual manipulation of the spine. However, no
additional payment is available for use of the device, nor does Medicare recognize an
extra charge for the device itself.
No other diagnostic or therapeutic service furnished by a chiropractor or under the
chiropractor’s order is covered. This means that if a chiropractor orders, takes, or
interprets an x-ray, or any other diagnostic test, the x-ray or other diagnostic test, can be
used for claims processing purposes, but Medicare coverage and payment are not
available for those services. This prohibition does not affect the coverage of x-rays or
other diagnostic tests furnished by other practitioners under the program. For example,
an x-ray or any diagnostic test taken for the purpose of determining or demonstrating the
existence of a subluxation of the spine is a diagnostic x-ray test covered under
§1861(s)(3) of the Act if ordered, taken, and interpreted by a physician who is a doctor of
medicine or osteopathy.
Manual devices (i.e., those that are hand-held with the thrust of the force of the device
being controlled manually) may be used by chiropractors in performing manual
manipulation of the spine. However, no additional payment is available for use of the
device, nor does Medicare recognize an extra charge for the device itself.
Effective for claims with dates of service on or after January 1, 2000, an x-ray is not
required to demonstrate the subluxation. However, an x-ray may be used for this purpose
if the chiropractor so chooses.
The word “correction” may be used in lieu of “treatment.” Also, a number of different
terms composed of the following words may be used to describe manual manipulation as
defined above:
• Spine or spinal adjustment by manual means;
• Spine or spinal manipulation;
• Manual adjustment; and
• Vertebral manipulation or adjustment.
In any case in which the term(s) used to describe the service performed suggests that it
may not have been treatment by means of manual manipulation, the A/B MAC (B)
analyst refers the claim for professional review and interpretation.
240.1.2 - Subluxation May Be Demonstrated by X-Ray or Physician’s
Exam
(Rev. 1, 10-01-03)
B3-2251.2
Subluxation is defined as a motion segment, in which alignment, movement integrity,
and/or physiological function of the spine are altered although contact between joint
surfaces remains intact.
A subluxation may be demonstrated by an x-ray or by physical examination, as described
below.
1. Demonstrated by X-Ray
An x-ray may be used to document subluxation. The x-ray must have been taken at a
time reasonably proximate to the initiation of a course of treatment. Unless more specific
x-ray evidence is warranted, an x-ray is considered reasonably proximate if it was taken
no more than 12 months prior to or 3 months following the initiation of a course of
chiropractic treatment. In certain cases of chronic subluxation (e.g., scoliosis), an older
x-ray may be accepted provided the beneficiary’s health record indicates the condition
has existed longer than 12 months and there is a reasonable basis for concluding that the
condition is permanent. A previous CT scan and/or MRI is acceptable evidence if a
subluxation of the spine is demonstrated.
2. Demonstrated by Physical Examination
Evaluation of musculoskeletal/nervous system to identify:
Pain/tenderness evaluated in terms of location, quality, and intensity;
Asymmetry/misalignment identified on a sectional or segmental level;
Range of motion abnormality (changes in active, passive, and accessory joint
movements resulting in an increase or a decrease of sectional or segmental mobility);
and
Tissue, tone changes in the characteristics of contiguous, or associated soft tissues,
including skin, fascia, muscle, and ligament.
To demonstrate a subluxation based on physical examination, two of the four criteria
mentioned under “physical examination” are required, one of which must be
asymmetry/misalignment or range of motion abnormality.
The history recorded in the patient record should include the following:
Symptoms causing patient to seek treatment;
Family history if relevant;
Past health history (general health, prior illness, injuries, or hospitalizations;
medications; surgical history);
Mechanism of trauma;
Quality and character of symptoms/problem;
Onset, duration, intensity, frequency, location and radiation of symptoms;
Aggravating or relieving factors; and
Prior interventions, treatments, medications, secondary complaints.
A. Documentation Requirements: Initial Visit
The following documentation requirements apply whether the subluxation is
demonstrated by x-ray or by physical examination:
1. History as stated above.
2. Description of the present illness including:
Mechanism of trauma;
Quality and character of symptoms/problem;
Onset, duration, intensity, frequency, location, and radiation of symptoms;
Aggravating or relieving factors;
Prior interventions, treatments, medications, secondary complaints; and
Symptoms causing patient to seek treatment.
These symptoms must bear a direct relationship to the level of subluxation. The
symptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or
osteo), rib (costo or costal) and joint (arthro) and be reported as pain (algia),
inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of
spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and
foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in
general other symptoms must relate to the spine as such. The subluxation must be causal,
i.e., the symptoms must be related to the level of the subluxation that has been cited. A
statement on a claim that there is “pain” is insufficient. The location of pain must be
described and whether the particular vertebra listed is capable of producing pain in the
area determined.
3. Evaluation of musculoskeletal/nervous system through physical examination.
4. Diagnosis: The primary diagnosis must be subluxation, including the level of
subluxation, either so stated or identified by a term descriptive of subluxation. Such
terms may refer either to the condition of the spinal joint involved or to the direction of
position assumed by the particular bone named.
5. Treatment Plan: The treatment plan should include the following:
Recommended level of care (duration and frequency of visits);
Specific treatment goals; and
Objective measures to evaluate treatment effectiveness.
6. Date of the initial treatment.
B. Documentation Requirements: Subsequent Visits
The following documentation requirements apply whether the subluxation is
demonstrated by x-ray or by physical examination:
1. History
Review of chief complaint;
Changes since last visit;
System review if relevant.
2. Physical exam
Exam of area of spine involved in diagnosis;
Assessment of change in patient condition since last visit;
Evaluation of treatment effectiveness.
3. Documentation of treatment given on day of visit.
240.1.3 - Necessity for Treatment
(Rev. 23, Issued: 10-08-04, Effective: 10-01-04, Implementation: 10-04-04)
The patient must have a significant health problem in the form of a neuromusculoskeletal
condition necessitating treatment, and the manipulative services rendered must have a
direct therapeutic relationship to the patient’s condition and provide reasonable
expectation of recovery or improvement of function. The patient must have a subluxation
of the spine as demonstrated by x-ray or physical exam, as described above.
Most spinal joint problems fall into the following categories:
• Acute subluxation-A patient’s condition is considered acute when the patient is
being treated for a new injury, identified by x-ray or physical exam as specified
above. The result of chiropractic manipulation is expected to be an improvement
in, or arrest of progression, of the patient’s condition.
• Chronic subluxation-A patient’s condition is considered chronic when it is not
expected to significantly improve or be resolved with further treatment (as is the
case with an acute condition), but where the continued therapy can be expected to
result in some functional improvement. Once the clinical status has remained
stable for a given condition, without expectation of additional objective clinical
improvements, further manipulative treatment is considered maintenance therapy
and is not covered.
For Medicare purposes, a chiropractor must place an AT modifier on a claim when
providing active/corrective treatment to treat acute or chronic subluxation. However the
presence of the AT modifier may not in all instances indicate that the service is
reasonable and necessary. As always, contractors may deny if appropriate after medical
review.
A. Maintenance Therapy
Maintenance therapy includes services that seek to prevent disease, promote health and
prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic
condition. When further clinical improvement cannot reasonably be expected from
continuous ongoing care, and the chiropractic treatment becomes supportive rather than
corrective in nature, the treatment is then considered maintenance therapy. The AT
modifier must not be placed on the claim when maintenance therapy has been provided.
Claims without the AT modifier will be considered as maintenance therapy and denied.
Chiropractors who give or receive from beneficiaries an ABN shall follow the
instructions in Pub. 100-04, Medicare Claims Processing Manual, chapter 23, section
20.9.1.1 and include a GA (or in rare instances a GZ) modifier on the claim.
B. Contraindications
Dynamic thrust is the therapeutic force or maneuver delivered by the physician during
manipulation in the anatomic region of involvement. A relative contraindication is a
condition that adds significant risk of injury to the patient from dynamic thrust, but does
not rule out the use of dynamic thrust. The doctor should discuss this risk with the
patient and record this in the chart. The following are relative contraindications to
dynamic thrust:
Articular hyper mobility and circumstances where the stability of the joint is
uncertain;
Severe demineralization of bone;
Benign bone tumors (spine);
Bleeding disorders and anticoagulant therapy; and
Radiculopathy with progressive neurological signs.
Dynamic thrust is absolutely contraindicated near the site of demonstrated subluxation
and proposed manipulation in the following:
Acute arthropathies characterized by acute inflammation and ligamentous laxity
and anatomic subluxation or dislocation; including acute rheumatoid arthritis and
ankylosing spondylitis;
Acute fractures and dislocations or healed fractures and dislocations with signs of
instability;
An unstable os odontoideum;
Malignancies that involve the vertebral column;
Infection of bones or joints of the vertebral column;
Signs and symptoms of myelopathy or cauda equina syndrome;
For cervical spinal manipulations, vertebrobasilar insufficiency syndrome; and
A significant major artery aneurysm near the proposed manipulation.
240.1.4 – Location of Subluxation
(Rev. 1, 10-01-03)
B3-2251.4
The precise level of the subluxation must be specified by the chiropractor to substantiate
a claim for manipulation of the spine. This designation is made in relation to the part of
the spine in which the subluxation is identified:
Area of Spine Names of Vertebrae
Number of
Vertebrae
Short Form or
Other Name
Neck Occiput 7 Occ, CO
Cervical C1 thru C7
Atlas C1
Axis C2
Back Dorsal or 12 D1 thru D12
Thoracic T1 thru T12
Area of Spine Names of Vertebrae
Number of
Vertebrae
Short Form or
Other Name
Costovertebral R1 thru R12
Costotransverse R1 thru R12
Low Back Lumbar 5 L1 thru L5
Pelvis IIii, r and 1 I, Si
Sacral Sacrum, Coccyx S, SC
In addition to the vertebrae and pelvic bones listed, the Ilii (R and L) are included with
the sacrum as an area where a condition may occur which would be appropriate for
chiropractic manipulative treatment.
There are two ways in which the level of the subluxation may be specified.
The exact bones may be listed, for example: C5, C6, etc.
The area may suffice if it implies only certain bones such as: Occipito-atlantal
(occiput and C1 (atlas)), lumbo-sacral (L5 and Sacrum), sacro-iliac (sacrum and
ilium).
Following are some common examples of acceptable descriptive terms for the nature of
the abnormalities:
Off-centered
Misalignment
Malpositioning
Spacing - abnormal, altered, decreased, increased
Incomplete dislocation
Rotation
Listhesis - antero, postero, retro, lateral, spondylo
Motion - limited, lost, restricted, flexion, extension, hyper mobility, hypomotility,
aberrant
Other terms may be used. If they are understood clearly to refer to bone or joint space or
position (or motion) changes of vertebral elements, they are acceptable.
240.1.5 - Treatment Parameters
(Rev. 23, Issued: 10-08-04, Effective: 10-01-04, Implementation: 10-04-04)
B3-2251.5
The chiropractor should be afforded the opportunity to effect improvement or arrest or
retard deterioration in such condition within a reasonable and generally predictable
period of time. Acute subluxation (e.g., strains or sprains) problems may require as many
as three months of treatment but some require very little treatment. In the first several
days, treatment may be quite frequent but decreasing in frequency with time or as
improvement is obtained.
Chronic spinal joint condition implies, of course, the condition has existed for a longer
period of time and that, in all probability, the involved joints have already “set” and
fibrotic tissue has developed. This condition may require a longer treatment time, but not
with higher frequency.
Some chiropractors have been identified as using an “intensive care” concept of
treatment. Under this approach multiple daily visits (as many as four or five in a single
day) are given in the office or clinic and so-called room or ward fees are charged since
the patient is confined to bed usually for the day. The room or ward fees are not covered
and reimbursement under Medicare will be limited to not more than one treatment per
day.
250 - Medical and Other Health Services Furnished to Inpatients of
Hospitals and Skilled Nursing Facilities
(Rev. 182, Issued: 03-21-14, Effective: 10-01-13, Implementation: 04-21-14)
There are several services which, when provided to a hospital or SNF inpatient, are
covered under Part B, even though the patient has Part A coverage for the hospital or
SNF stay. Those services are:
Physicians’ services (including the services of residents and interns in unapproved
teaching programs);
Physician assistant services, furnished after December 31, 1990;
Certified nurse-midwife services, as described in §180, furnished after December
31, 1990; and
Qualified clinical psychologist services, as defined in §160, furnished after
December 31, 1990;
Screening mammography services;
Screening pap smears and pelvic exams;
Screening glaucoma services;
Influenza, pneumococcal pneumonia, and hepatitis B vaccines and their
administrations;
Colorectal screening;
Bone mass measurements; and
Prostate screening;
Pneumococcal and hepatitis B vaccine services must be provided directly or arranged for
by the hospital in order to be covered when furnished to a hospital inpatient. The other
services listed are not subject to bundling but, because they are excluded from the
statutory definition of inpatient hospital services, may be covered only under Part B.
Payment may be made under Part B to a hospital (or critical access hospital) for certain
medical and other health services furnished to its inpatients as provided in Chapter 6, §10
of this manual, “Medical and Other Health Services Furnished to Inpatients of
Participating Hospitals.”
Payment may be made under Part B for certain medical and other health services if the
beneficiary is an inpatient of a skilled nursing facility (SNF) as provided in chapter 8, §§
70ff of this manual.
260 - Ambulatory Surgical Center Services
(Rev. 77; Issued: 08-29-07; Effective: 01-01-08; Implementation: 01-07-08)
Facility services furnished by ambulatory surgical centers (ASCs) in connection with
certain surgical procedures are covered under Part B. To receive coverage of and
payment for its services under this provision, a facility must be certified as meeting the
requirements for an ASC and enter into a written agreement with CMS. Medicare
periodically updates the list of covered procedures and related payment amounts through
release of regulations and change requests. The ASC must accept Medicare’s payment
for such procedures as payment in full with respect to those services defined as ASC
facility services.
Where services are performed in an ASC, the physician and others who perform covered
services may also be paid for his/her professional services; however, the “professional”
rate is then adjusted since the ASC incurs the facility costs.
260.1 - Definition of Ambulatory Surgical Center (ASC)
(Rev. 104; Issued: 03-13-09; Effective Date: 04-01-09; Implementation Date: 04-
06-09)
An ASC for purposes of this benefit is a distinct entity that operates exclusively for the
purpose of furnishing outpatient surgical services to patients. It enters into an agreement
with CMS to do so. An ASC is either independent (i.e., not a part of a provider of
services or any other facility), or operated by a hospital (i.e., under the common
ownership, licensure, or control of a hospital). To be covered as an ASC operated by a
hospital, a facility elects to do so, and continues to be so covered unless CMS determines
there is good cause to do otherwise. This provision is intended to prohibit such an entity
from switching from one payment method to another to maximize its revenues (47 FR
34082, 34099, Aug. 5, 1982). For other general conditions and requirements, see 42 CFR
416.25-416.49. If the hospital based surgery center is certified as an ASC it is considered
an ASC and is subject to rules for ASCs. Related survey requirements are published in
the State Operations Manual, Pub. 100-07, Appendix L. Claims processing and payment
requirements for ASCs are published in Pub. 100-04, the Medicare Claims Processing
Manual, chapter 14.
If a hospital based surgery center is not certified as an ASC it continues under the
program as part of the hospital. In that case the applicable hospital outpatient payment
rules apply. This is the outpatient prospective payment system (OPPS), for most
hospitals, or may be provisions for hospitals excluded from OPPS. See Pub.100-04, the
Medicare Claims Processing Manual, chapter 4, for billing and payment requirements for
hospital outpatient services.
Indian Health Service (IHS) hospital outpatient departments are not certified as separate
ASC entities. The ASC indication merely means that CMS approved them to bill for
ASC services and be paid based on the ASC rates for services on the ASC list. In order
to bill for ASC services, the hospital outpatient department must meet the conditions of
participation for hospitals defined at 42 CFR, Part 482. See Pub. 100-04, the Medicare
Claims Processing Manual, chapter 19, sections 40.2.1, and 80.9 for more information on
IHS hospital outpatient departments billing for ASC services.
260.2 - Ambulatory Surgical Center Services
(Rev. 77; Issued: 08-29-07; Effective: 01-01-08; Implementation: 01-07-08)
The ASC facility services are services furnished in an ASC in connection with a covered
surgical procedure that are otherwise covered if furnished on an inpatient or outpatient
basis in a hospital in connection with that procedure. Not included in the definition of
facility services are medical and other health services, even though furnished within the
ASC, which are covered under other portions of the Medicare program, or not furnished
in connection with covered surgical procedures. This distinction between covered ASC
facility services and services which are not covered ASC facility services is important,
since the facility payment rate includes only the covered ASC facility services. Services,
which are not covered ASC facility services such as physicians’ services and prosthetic
devices other than intraocular lenses (IOLs), may be covered and billable under other
Medicare provisions.
Since there is no uniformity among ASCs as to what items and services they include in
their facility fee or charge, the Medicare definition of covered facility services is both
inclusive and exclusive. The regulations specify what are and are not facility services.
Facility services are items and services furnished in connection with listed covered
procedures, which are covered if furnished in a hospital operating suite or hospital
outpatient department in connection with such procedures. These do not include
physicians’ services, or medical and other health services for which payment may be
made under other Medicare provisions (e.g., services of an independent laboratory
located on the same site as the ASC, anesthetist professional services, non-implantable
DME).
Examples of covered ASC facility services include:
Nursing Services, Services of Technical Personnel, and Other Related Services
These include all services in connection with covered procedures furnished by nurses and
technical personnel who are employees of the ASC. In addition to the nursing staff, this
category includes orderlies, technical personnel, and others involved in patient care;
Use by the Patient of the ASC’s Facilities
This category includes operating and recovery rooms, patient preparation areas, waiting
rooms, and other areas used by the patient or offered for use by the patient’s relatives in
connection with surgical services; and
Drugs, Biologicals, Surgical Dressings, Supplies, Splints, Casts, Appliances, and
Equipment
This category includes all supplies and equipment commonly furnished by the ASC in
connection with surgical procedures. See below for certain exceptions. Drugs and
biologicals are limited to those that cannot be self-administered. (See §60.)
Coverage policy for surgical dressings is similar to that followed under Part B. Under
Part B, coverage for surgical dressings is limited to primary dressings; i.e., therapeutic
and protective coverings applied directly to lesions on the skin or on openings to the skin
required as the result of surgical procedures. (Items such as Ace bandages, elastic
stockings and support hose, Spence boots and other foot coverings, leotards, knee
supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are
generally used as secondary coverings and therefore are not covered as surgical
dressings.) Surgical dressings usually are applied first by a physician and are covered as
“incident to” a physician’s service in a physician’s office setting. In the ASC setting,
such dressings are included in the facility’s services.
However, others may reapply surgical dressings later, including the patient or a member
of the patient’s family. When the patient on a physician’s order obtains surgical
dressings from a supplier, e.g., a drugstore, the surgical dressing is covered under Part B.
The same policy applies in the case of dressings obtained by the patient on a physician’s
order following surgery in an ASC; the dressings are covered and paid as a Part B service
by the local A/B MAC (B), included in the definition of facility services.
Similarly, “other supplies, splints, and casts” include only those furnished by the ASC at
the time of the surgery. Additional covered supplies and materials furnished later are
generally furnished as “incident to” a physician’s service, not as an ASC facility service.
The term “supplies” includes those required for both the patient and ASC personnel, e.g.,
gowns, masks, drapes, hoses, and scalpels, whether disposable or reusable.
Diagnostic or Therapeutic Items and Services
These are items and services furnished by ASC staff in connection with covered surgical
procedures. With respect to diagnostic tests, many ASCs perform simple tests just before
surgery, primarily urinalysis and blood hemoglobin or hematocrit, which are generally
included in their facility charges. To the extent that such simple tests are included in the
ASC’s facility charges, they are considered facility services. However, under the
Medicare program, diagnostic tests are not covered in laboratories independent of a
physician’s office, rural health clinic, or hospital unless the laboratories meet the
regulatory requirements for the conditions for coverage of services of independent
laboratories. (See 42 CFR 416.49.) Therefore, diagnostic tests performed by the ASC
other than those generally included in the facility’s charge are not covered under Part B
as such and are not billed to the A/B MAC (B) as diagnostic tests. If the ASC has its
laboratory certified as meeting the regulatory conditions, then the laboratory itself bills
the A/B MAC (B) (or the beneficiary) for the tests performed.
The ASC may make arrangements with an independent laboratory or other laboratory,
such as a hospital laboratory, to perform diagnostic tests it requires prior to surgery. In
general, however, the necessary laboratory tests are done outside the ASC prior to
scheduling of surgery, since the test results often determine whether the beneficiary
should even have the surgery done on an outpatient basis in the first place.
Administrative, Recordkeeping, and Housekeeping Items and Services
These include the general administrative functions necessary to run the facility e.g.,
scheduling, cleaning, utilities, and rent.
Blood, Blood Plasma, Platelets, etc., Except Those to Which Blood Deductible
Applies
While covered procedures are limited to those not expected to result in extensive loss of
blood, in some cases, blood or blood products are required. Usually the blood deductible
results in no expenses for blood or blood products being included under this provision.
However, where there is a need for blood or blood products beyond the deductible, they
are considered ASC facility services and no separate charge is permitted to the
beneficiary or the program.
Materials for Anesthesia
These include the anesthetic itself, and any materials, whether disposable or reusable,
necessary for its administration.
Intraocular Lenses (IOLs)
Effective for services furnished on or after March 12, 1990, ASC facility services include
intraocular lenses approved by the Food and Drug Administration (FDA) for insertion
during or subsequent to cataract surgery.
FDA has classified IOLs into the following four categories, any of which are included:
Anterior chamber angle fixation lenses;
Iris fixation lenses;
Irido-capsular fixation lenses; and
Posterior chamber lenses.
While FDA has approved many IOLs, it still considers some IOLs investigational. The
fact that they are covered under Medicare is an exception to the general policy not to
cover experimental or investigational items or services. The exception is made because
the Congress, recognizing the widespread use of IOLs, directed the FDA to study them
without interfering with availability to patients.
The A/B MAC (B) determines whether the item or service falls into the categories
described in the following section. If it determines the item or service does fall into one
of those categories, it makes payment following the applicable rules for such items and
services found elsewhere in this chapter. If the item or service does not fall into one of
the categories described, the A/B MAC (B) denies the claim.
Covered ASC surgical procedures are those surgical procedures that are identified by
CMS on an annually updated ASC listing. Some surgical procedures covered by
Medicare are not on the ASC list of covered surgical procedures.
Under the revised ASC payment system, Medicare makes facility payments to ASCs only
for the specific ASC covered surgical procedures and covered ancillary services that are
provided integral to a covered ASC surgical procedure.
See chapter 14, section 10 of Pub. 100-04, Medicare Claims Processing Manual for
examples of covered ASC services for which payment is included in the ASC payment
for a covered surgical procedure under 42CFR416.65.
There is a payment adjustment for insertion of an IOL approved as belonging to a class of
NTIOLs, for the 5-year period of time established for that class, as set forth at
42CFR416.200.
260.3 - Services Furnished in ASCs Which are Not ASC Facility
Services
(Rev. 1, 10-01-03)
B3-2265.3
A single payment is made to an ASC that encompasses all “facility services” furnished by
the ASC in connection with a covered procedure. However, a number of items and
services covered under Medicare may be furnished in an ASC which are not considered
facility services, and which the ASC payment does not include. These non-ASC services
are covered and paid for under the applicable provisions of Part B. In addition, the ASC
may be part of a medical complex that includes other entities, such as an independent
laboratory, supplier of durable medical equipment, or a physician’s office, which are
covered as separate entities under Part B. In general, an item or service separately
covered under Medicare is not considered an ASC service. Examples of services payable
in addition to ASC services are found in §260.4.
260.4 - Coverage of Services in ASCs, Which are Not ASC Services
(Rev. 77; Issued: 08-29-07; Effective: 01-01-08; Implementation: 01-07-08)
Physicians’ Services
This category includes most covered services performed in ASCs, which are not
considered ASC facility services. Physicians’ services were covered before coverage of
ASC services, and the ASC amendment did not change this. Consequently, physicians
who perform covered services in ASCs receive payment under the existing Part B system.
Physicians’ services include the services of anesthesiologists administering or
supervising the administration of anesthesia to beneficiaries in ASC’s and the
beneficiaries’ recovery from the anesthesia. The term physicians’ services also includes
any routine pre- or post-operative services, such as office visits, consultations, diagnostic
tests, removal of stitches, changing of dressings, and other services that the individual
physician usually includes in the fee for a given surgical procedure.. The contractor
applies the same criteria, limits and understandings to physicians’ services for procedures
furnished in the ASC that are applied to the procedures furnished by the same physicians
on an inpatient hospital basis.
The Sale, Lease, or Rental of Durable Medical Equipment (DME) to ASC Patients
for Use in Their Homes
Non-implantable Durable Medical Equipment (DME) - If the ASC furnishes items of
non-implantable DME to beneficiaries, it is treated as a DME supplier, and all the rules
and conditions ordinarily applicable to DME are applicable, including obtaining a
supplier number and billing the DME MAC where applicable.
Prosthetic Devices
Prosthetic devices, other than intraocular lenses (IOLs), whether implanted, inserted, or
otherwise applied by covered surgical procedures, are covered, but are not included in the
ASC facility payment amount. However, §4063(b) of P.L. 100-203 amended §1833
(i)(2)(A) of the Act to mandate that payment for an intraocular lens (IOL) inserted during
or subsequent to cataract surgery in an ASC be included in the facility payment rate.
This bundling of the payment for an IOL with the facility fee is effective for services
furnished on or after March 12, 1990. More information on coverage of prosthetic
devices may be found in §120. Further information on the coverage of IOLs may be
found in §260.2.
Non-Implantable Prosthetic Devices - If the ASC furnishes non-implantable prosthetic
devices to beneficiaries, the ASC is treated as a supplier, and all the rules and conditions
ordinarily applicable to suppliers are applicable, including obtaining a supplier number
and billing the DME MAC where applicable.
Ambulance Services
If the ASC furnishes ambulance services, they are covered as ambulance services
pursuant to the terms and conditions of the Medicare Benefit Policy Manual, Chapter 10,
“Ambulance Services,” §§10. The facility may obtain approval as an ambulance supplier
to bill covered ambulance services.
Leg, Arm, Back, and Neck Braces
These items of equipment, like prosthetic devices, are covered under Part B, but are not
included in the ASC facility payment amount. Coverage of these items is described in
§130. If the ASC furnishes these to beneficiaries, it is treated as a supplier, and all the
rules and conditions ordinarily applicable to suppliers are applicable, including obtaining
a supplier number and billing the DME MAC where applicable.
Artificial Legs, Arms, and Eyes
Like prosthetic devices and braces, this equipment is not considered part of an ASC
facility service and so is not included in the ASC facility payment rate. Information
regarding the coverage of these items is set out in §130. If the ASC furnishes these items
to beneficiaries, it is treated as a supplier, and all the rules and conditions ordinarily
applicable to suppliers are applicable, including obtaining a supplier number and billing
the DME MAC where applicable.
Services of Independent Laboratory
As noted in §260.2, only a very limited number and type of diagnostic tests are
considered ASC facility services and included in the ASC facility payment rate. In most
cases, diagnostic tests performed directly by an ASC are not considered ASC facility
services and are not covered under Medicare. Section 1861(s) of the Act limits coverage
of diagnostic lab tests in facilities other than physicians’ offices, rural health clinics, or
hospitals to facilities that meet the statutory definition of an independent laboratory. (See
§§80.1 for a description of independent laboratories and covered services.) In order to
bill for diagnostic tests as a laboratory, an ASC’s laboratory must be CLIA certified and
enrolled with the contactor as a laboratory and the certified clinical laboratory must bill
for the services provided to the beneficiary in the ASC. Otherwise, the ASC makes
arrangements with a covered laboratory or laboratories for laboratory services, as
provided in 42 CFR 416.49. If the ASC has a certified independent laboratory, the
laboratory itself bills the A/B MAC (B), pursuant to §§80.
260.5 - List of Covered Ambulatory Surgical Center Procedures
(Rev. 77; Issued: 08-29-07; Effective: 01-01-08; Implementation: 01-07-08)
The law ties coverage of ambulatory surgical center (ASC) services under Part B to
specified surgical procedures, which are contained in a list revised and published
periodically by CMS. Groupings and related prices are also published periodically.
These are published in the Federal Register and on the CMS Web site.
Beginning January 1, 2008, under the revised ASC payment system, CMS will update the
list of covered surgical procedures, relative payment weights and national unadjusted
payment rates, annually. The updates will be proposed and finalized in the Federal
Register concurrent with updates to the hospital outpatient prospective payment system.
260.5.1 - Nature and Applicability of ASC List
(Rev. 77; Issued: 08-29-07; Effective: 01-01-08; Implementation: 01-07-08)
The ASC list of covered surgical procedures indicates procedures that are covered and
may be paid for if performed in the ASC setting. There is no requirement that the
covered surgical procedures be performed only in ASCs. The decision regarding the
most appropriate care setting for a given surgical procedure is made by the physician
based on the beneficiary’s individual clinical needs and preferences. Also, all the general
coverage rules requiring that any procedure be reasonable and necessary for the
beneficiary are applicable to ASC services in the same manner as all other covered
services.
260.5.2 - Nomenclature and Organization of the List
(Rev. 77; Issued: 08-29-07; Effective: 01-01-08; Implementation: 01-07-08)
The listed procedures are all considered “surgical procedures” for coverage purposes
under the ASC provision, regardless of the specific use to which the procedure is put.
For example, many of the “oscopy” procedures listed - bronchoscopy, laryngoscopy, etc.,
may be employed for either diagnostic or therapeutic purposes, or both at the same time,
such as when the “oscopy” permits both detection and removal of a polyp. Those
procedures are considered “surgical procedures” within the context of the ASC provision.
Also, surgical procedures are commonly thought of as those involving an incision of
some type, whether done with a scalpel or (more recently) a laser, followed by removal
or repair of an organ or other tissue. In recent years, the development of fiber optics
technology, together with new surgical instruments utilizing that technology, has resulted
in surgical procedures that, while invasive and manipulative, do not require incisions.
Instead, the procedures are performed without an incision through various body openings.
Those procedures, some of which include the “oscopy” procedures mentioned above, are
also considered surgical procedures for purposes of the ASC provision, and several are
included in the list of covered procedures.
Beginning January 1, 2008, the ASC list of covered surgical procedures is comprised of
surgical procedures that CMS determines do not pose a significant safety risk and are not
expected to require an overnight stay following the surgical procedure.
Surgical procedures are defined as Category I CPT codes within the surgical range of
CPT codes, 10000 through 69999. Also considered to be included within that code range
are Level II HCPCS and Category III CPT codes that crosswalk to or are clinically
similar to the Category I CPT codes in the range.
The surgical codes that are included on the ASC list of covered surgical procedures are
those that have been determined to pose no significant safety risk to Medicare
beneficiaries when furnished in ASCs and that are not expected to require active medical
monitoring at midnight of the day on which the surgical procedure is performed
(overnight stay).
Procedures that are included on the inpatient list used under Medicare’s hospital
outpatient prospective payment system and procedures that can only be reported by using
an unlisted Category I CPT code are deemed to pose significant safety risk to
beneficiaries in ASCs and are not eligible for designation and coverage as covered
surgical procedures.
260.5.3 - Rebundling of CPT Codes
(Rev. 1, 10-01-03)
B3-2266.3
Instructions regarding the Correct Coding Initiative apply to coverage of ASC facility
services.
270 - Telehealth Services
(Rev. 221, Issued: 03-11-16, Effective: 01-01-15, Effective: 04-11-16)
For information on telehealth services, see Pub. 100-04, Medicare Claims Processing
Manual, chapter 12, section 190.
280 – Preventive and Screening Services
(Rev. 11355; Issued:04-14-22; Effective: 05-16-22; Implementation: 05-16-22)
See section 50.4.4.2 for coverage requirements for PPV, hepatitis B vaccine, Influenza
Virus Vaccine, and COVID-19 vaccines.
See Pub. 100-04, Medicare Claims Processing Manual, Chapter 18, “Preventive and
Screening Services,” for coverage requirements for the following:
• §40 for screening pelvic examinations,
• §50 for prostate cancer screening test and procedures,
• §60 for colorectal cancer screening, and,
• §70.4 for glaucoma screening.
280.1 – Glaucoma Screening
(Rev. 194, Issued: 09-03-14, Effective: Upon Implementation of ICD-10,
Implementation: Upon Implementation of ICD-10)
A. Conditions of Coverage
The regulations implementing the Benefits Improvements and Protection Act of 2000,
§102, provide for annual coverage for glaucoma screening for beneficiaries in the
following high risk categories:
• Individuals with diabetes mellitus;
• Individuals with a family history of glaucoma; or
• African-Americans age 50 and over.
In addition, beginning with dates of service on or after January 1, 2006, 42 CFR
410.23(a)(2), revised, the definition of an eligible beneficiary in a high-risk category is
expanded to include:
• Hispanic-Americans age 65 and over.
Medicare will pay for glaucoma screening examinations where they are furnished by or
under the direct supervision in the office setting of an ophthalmologist or optometrist,
who is legally authorized to perform the services under State law.
Screening for glaucoma is defined to include:
• A dilated eye examination with an intraocular pressure measurement; and
• A direct ophthalmoscopy examination, or a slit-lamp biomicroscopic examination.
Payment may be made for a glaucoma screening examination that is performed on an
eligible beneficiary after at least 11 months have passed following the month in which the
last covered glaucoma screening examination was performed.
The following HCPCS codes apply for glaucoma screening:
G0117 - Glaucoma screening for high-risk patients furnished by an optometrist or
ophthalmologist; and
G0118 - Glaucoma screening for high-risk patients furnished under the direct
supervision of an optometrist or ophthalmologist.
The type of service for the above G codes is: TOS Q.
For providers who bill A/B MACs, applicable types of bill for screening glaucoma
services are 13X, 22X, 23X, 71X, 73X, 75X, and 85X. The following revenue codes
should be reported when billing for screening glaucoma services:
• Comprehensive outpatient rehabilitation facilities (CORFs), critical access
hospitals (CAHs), skilled nursing facilities (SNFs), independent and provider-
based RHCs and free standing and provider-based FQHCs bill for this service
under revenue code 770. CAHs electing the optional method of payment for
outpatient services report this service under revenue codes 96X, 97X, or 98X.
• Hospital outpatient departments bill for this service under any valid/appropriate
revenue code. They are not required to report revenue code 770.
o Calculating the Frequency
• Once a beneficiary has received a covered glaucoma screening procedure, the
beneficiary may receive another procedure after 11 full months have passed. To
determine the 11-month period, start the count beginning with the month after the
month in which the previous covered screening procedure was performed.
o Diagnosis Coding Requirements
• Providers bill glaucoma screening using diagnosis codes for screening services.
Claims submitted without a screening diagnosis code may be returned to the
provider as unprocessable.
o Payment Methodology
• A/B MACs (B)
o Contractors pay for glaucoma screening based on the Medicare physician fee
schedule. Deductible and coinsurance apply. Claims from physicians or other
providers where assignment was not taken are subject to the Medicare limiting
charge (refer to the Medicare Claims Processing Manual, Chapter 12,
“Physician/Non-physician Practitioners,” for more information about the
Medicare limiting charge).
• A/B MACs (A)
o Payment is made for the facility expense as follows:
• Independent and provider-based RHC/free standing and provider-based FQHC -
payment is made under the all inclusive rate for the screening glaucoma service
based on the visit furnished to the RHC/FQHC patient;
• CAH - payment is made on a reasonable cost basis unless the CAH has elected
the optional method of payment for outpatient services in which case, procedures
outlined in the Medicare Claims Processing Manual, Chapter 3, §30.1.1, should
be followed;
• CORF - payment is made under the Medicare physician fee schedule;
• Hospital outpatient department - payment is made under outpatient prospective
payment system (OPPS);
• Hospital inpatient Part B - payment is made under OPPS;
• SNF outpatient - payment is made under the Medicare physician fee schedule
(MPFS); and
• SNF inpatient Part B - payment is made under MPFS.
Deductible and coinsurance apply.
E. Special Billing Instructions for RHCs and FQHCs
Screening glaucoma services are considered RHC/FQHC services. RHCs and FQHCs
bill the contractor under bill type 71X or 73X along with revenue code 770 and HCPCS
codes G0117 or G0118 and RHC/FQHC revenue code 520 or 521 to report the related
visit. Reporting of revenue code 770 and HCPCS codes G0117 and G0118 in addition to
revenue code 520 or 521 is required for this service in order for CWF to perform
frequency editing.
Payment should not be made for a screening glaucoma service unless the claim also
contains a visit code for the service. Therefore, the contractor installs an edit in its
system to assure payment is not made for revenue code 770 unless the claim also contains
a visit revenue code (520 or 521).
280.2 - Colorectal Cancer Screening
(Rev. 1, 10-01-03)
B3-4180
280.2.1 - Covered Services and HCPCS Codes
See Business Requirements at http://cms.hhs.gov/manuals/pm_trans/R3BP.pdf
(Rev. 3, 12-19-03)
B3-4180.1
Medicare covers colorectal cancer screening test/procedures for the early detection of
colorectal cancer for the HCPCS codes indicated.
A. Effective for Services Furnished On or After January 1, 1998:
G0107 - Colorectal cancer screening; fecal-Occult blood test, 1-3 simultaneous
determinations;
G0104 - Colorectal cancer screening; flexible sigmoidoscopy;
G0105 - Colorectal cancer screening; colonoscopy on individual at high risk;
G0106 - Colorectal cancer screening barium enema; alternative to GO104,
screening sigmoidoscopy;
G0120 - Colorectal cancer screening barium enema; alternative to GO105,
screening sigmoidoscopy.
B. Effective for Services Furnished On or After July 1, 2001:
G0121 - Colorectal Cancer Screening; Colonoscopy on Individual Not Meeting
Criteria for High Risk
C. Effective for Services Furnished On or After January 1, 2004:
G0328 - Colorectal cancer screening; fecal-occult blood test, immunoassay, 1-3
simultaneous determinations.
280.2.2 - Coverage Criteria
(Rev. 12299; Issued:10-12-23; Effective:01-01-23; Implementation:11-13-23)
The following are the coverage criteria for these screenings:
A. Screening Fecal-Occult Blood Tests (FOBT) (Codes 82270 & G0328)
Effective for services furnished on or after January 1, 2004, one
screening FOBT (code 82270 or G0328) is covered for beneficiaries who
have attained age 50, at a frequency of once every 12 months (i.e., at
least 11 months have passed following the month in which the last
covered screening FOBT was done). Screening FOBT means: (1) a
guaiac-based test for peroxidase activity in which the beneficiary
completes it by taking samples from two different sites of three
consecutive stools or, (2) an immunoassay (or immunochemical) test for
antibody activity in which the beneficiary completes the test by taking
the appropriate number of samples according to the specific
manufacturer’s instructions. This expanded coverage is in accordance
with revised regulations at 42 CFR 410.37(a)(2) that includes “ other
tests determined by the Secretary through a national coverage
determination.” This screening requires a written order from the
beneficiary’s attending physician or for claims with dates of service on or
after January 27, 2014, from the beneficiary’s attending physician
assistant, nurse practitioner, or clinical nurse specialist. (The term
“attending physician” is defined to mean a doctor of medicine or
osteopathy (as defined in §1861(r)(1) of the Act) who is fully
knowledgeable about the beneficiary’s medical condition, and who
would be responsible for using the results of any examination performed
in the overall management of the beneficiary’s specific medical
problem.)
NOTE: For claims with dates of service prior to January 1, 2007,
physicians, suppliers, and providers report HCPCS code G0107.
Effective January 1, 2007, code G0107, is discontinued and replaced
with CPT code 82270. For complete claims processing information refer
to Pub. 100-04, Medicare Claims Processing Manual, chapter 18, section
60.
Effective January 1, 2023, the minimum age for FOBT screening tests is
reduced to 45 years and older. For complete claims processing information,
refer to Pub 100-04, Medicare Claims Processing Manual, chapter 18, section
60.
B. Screening Flexible Sigmoidoscopies (code G0104)
For claims with dates of service on or after January 1, 2002, A/B MACs
(B) pay for screening flexible sigmoidoscopies (Code G0104) for
beneficiaries who have attained age 50 when these services were
performed by a doctor of medicine or osteopathy, or by a physician
assistant, nurse practitioner, or clinical nurse specialist (as defined in
§1861(aa)(5) of the Act and at 42 CFR 410.74, 410.75, and 410.76) at
the frequencies noted below. For claims with dates of service prior to
January 1, 2002, pay for these services under the conditions noted only
when they are performed by a doctor of medicine or osteopathy.
For services furnished from January 1, 1998, through June 30, 2001, inclusive
Once every 48 months (i.e., at least 47 months have passed following the
month in which the last covered screening flexible sigmoidoscopy was
done).
For services furnished on or after July 1, 2001
Once every 48 months as calculated above unless the beneficiary does
not meet the criteria for high risk of developing colorectal cancer (refer
to §280.2.3) and the beneficiary has had a screening colonoscopy (code
G0121) within the preceding 10 years. If such a beneficiary has had a
screening colonoscopy within the preceding 10 years, then he or she can
have covered a screening flexible sigmoidoscopy only after at least 119
months have passed following the month that he/she received the
screening colonoscopy (code G0121).
NOTE: If during the course of a screening flexible sigmoidoscopy a
lesion or growth is detected which results in a biopsy or removal of the
growth, the appropriate diagnostic procedure classified as a flexible
sigmoidoscopy with biopsy or removal should be billed and paid rather
than code G0104.
Effective January 1, 2023, the minimum age for Screening Flexible
Sigmoidoscopies is reduced to 45 years and older. For complete claims
processing information, refer to Pub 100-04, Medicare Claims
Processing Manual, chapter 18, section 60.
C. Screening Colonoscopies for Beneficiaries at High Risk of
Developing Colorectal Cancer (Code G0105)
The A/B MAC (B) must pay for screening colonoscopies (code G0105)
when performed by a doctor of medicine or osteopathy at a frequency of
once every 24 months for beneficiaries at high risk for developing
colorectal cancer (i.e., at least 23 months have passed following the
month in which the last covered G0105 screening colonoscopy was
performed). Refer to §280.2.3 for the criteria to use in determining
whether or not an individual is at high risk for developing colorectal
cancer.
NOTE: If during the course of the screening colonoscopy, a lesion or
growth is detected which results in a biopsy or removal of the growth,
the appropriate diagnostic procedure classified as a colonoscopy with
biopsy or removal should be billed and paid rather than code G0105.
Effective January 1, 2023, colorectal cancer screening tests include a follow-on
Screening Colonoscopy for Beneficiaries at High Risk of Developing Colorectal
Cancer after a Medicare covered non-invasive stool-based colorectal cancer screening
test returns a positive result. Non-invasive stool-based colorectal cancer screening
tests include:
• Screening Guaiac-based Fecal Occult Blood Test (gFOBT) (82270)
• Screening Immunoassay-based Fecal Occult Blood Test (iFOBT) (G0328)
• Screening The Cologuard™ – Multi-target Stool DNA (sDNA) Test (81528)
The frequency limitations described for Screening Colonoscopies for Beneficiaries at
High Risk of Developing Colorectal Cancer in this section shall not apply in the
instance of a follow-on Screening Colonoscopy for Beneficiaries at High Risk of
Developing Colorectal Cancer after a Medicare covered non-invasive stool-based
colorectal cancer screening test returns a positive result. For complete claims
processing information, refer to Pub 100-04, Medicare Claims Processing Manual,
chapter 18, section 60.
D. Screening Colonoscopies Performed on Individuals Not Meeting
the Criteria for Being at High-Risk for Developing Colorectal
Cancer (Code G0121)
Effective for services furnished on or after July 1, 2001, screening
colonoscopies (code G0121) are covered when performed under the
following conditions:
1. On individuals not meeting the criteria for being at high
risk for developing colorectal cancer (refer to §280.2.3);
2. At a frequency of once every 10 years (i.e., at least 119 months
have passed following the month in which the last covered
G0121 screening colonoscopy was performed); and
3. If the individual would otherwise qualify to have covered a
G0121 screening colonoscopy based on the above (see
§§280.2.2.D.1 and 2) but has had a covered screening flexible
sigmoidoscopy (code G0104), then the individual may have a
covered G0121 screening colonoscopy only after at least 47
months have passed following the month in which the last
covered G0104 flexible sigmoidoscopy was performed.
NOTE: I f during the course of the screening colonoscopy, a lesion or
growth is detected which results in a biopsy or removal of the growth,
the appropriate diagnostic procedure classified as a colonoscopy with
biopsy or removal should be billed and paid rather than code G0121.
Effective January 1, 2023, colorectal cancer screening tests include a follow-on
Screening Colonoscopy Performed on Individuals Not Meeting the Criteria for Being
at High-Risk for Developing Colorectal Cancer after a Medicare covered non-
invasive stool-based colorectal cancer screening test returns a positive result. Non-
invasive stool-based colorectal cancer screening tests include:
• Screening Guaiac-based Fecal Occult Blood Test (gFOBT) (82270)
• Screening Immunoassay-based Fecal Occult Blood Test (iFOBT) (G0328)
• Screening The Cologuard™ – Multi-target Stool DNA (sDNA) Test (81528)
The frequency limitations described for Colonoscopies Performed on Individuals Not
Meeting the Criteria for Being at High-Risk for Developing Colorectal Cancer in this
section shall not apply in the instance of a follow-on Screening Colonoscopy
Performed on Individuals Not Meeting the Criteria for Being at High-Risk for
Developing Colorectal Cancer after a Medicare covered non-invasive stool-based
colorectal cancer screening test returns a positive result. For complete claims
processing information, refer to Pub 100-04, Medicare Claims Processing Manual,
chapter 18, section 60.
E. Screening Barium Enema Examinations (codes G0106 and G0120)
Screening barium enema examinations are covered as an alternative to
either a screening sigmoidoscopy (code G0104) or a screening
colonoscopy (code G0105) examination.
The same frequency parameters for screening sigmoidoscopies and
screening colonoscopies above apply.
In the case of an individual aged 50 or over, payment may be made for a
screening barium enema examination (code G0106) performed after at
least 47 months have passed following the month in which the last
screening barium enema or screening flexible sigmoidoscopy was
performed. For example, the beneficiary received a screening barium
enema examination as an alternative to a screening flexible
sigmoidoscopy in January 1999. The count starts beginning February
1999. The beneficiary is eligible for another screening barium enema in
January 2003.
In the case of an individual who is at high risk for colorectal cancer,
payment may be made for a screening barium enema examination (code
G0120) performed after at least 23 months have passed following the
month in which the last screening barium enema or the last screening
colonoscopy was performed. For example, a beneficiary at high risk for
developing colorectal cancer received a screening barium enema
examination (code G0120) as an alternative to a screening colonoscopy
(code G0105) in January 2000. The count starts beginning February
2000. The beneficiary is eligible for another screening barium enema
examination (code G0120) in January 2002.
The screening barium enema must be ordered in writing after a
determination that the test is the appropriate screening test. Generally, it
is expected that this will be a screening double contrast enema unless the
individual is unable to withstand such an exam. This means that in the
case of a particular individual, the attending physician must determine
that the estimated screening potential for the barium enema is equal to or
greater than the screening potential that has been estimated for a
screening flexible sigmoidoscopy, or for a screening colonoscopy, as
appropriate, for the same individual. The screening single contrast
barium enema also requires a written order from the beneficiary’s
attending physician in the same manner as described above for the
screening double contrast barium enema examination.
Effective January 1, 2023, the minimum age for Screening Barium
Enema Examinations is reduced to 45 years and older. For complete
claims processing information, refer to Pub 100-04, Medicare Claims
Processing Manual, chapter 18, section 60.
280.2.3 - Determining Whether or Not the Beneficiary is at High Risk
for Developing Colorectal Cancer
(Rev. 194, Issued: 09-03-14, Effective: Upon Implementation of ICD-10,
Implementation: Upon Implementation of ICD-10)
A. Characteristics of the High Risk Individual
An individual at high risk for developing colorectal cancer has one or more of the
following:
A close relative (sibling, parent, or child) who has had colorectal cancer or an
adenomatous polyp;
A family history of familial adenomatous polyposis;
A family history of hereditary nonpolyposis colorectal cancer;
A personal history of colorectal cancer;
A personal history of adenomatous polyps;
Inflammatory bowel disease, including Crohn’s Disease, and ulcerative colitis.
B. Partial List of ICD-9-CM Codes Indicating High Risk (for Services before
Implementation of ICD-10)
Listed below are some examples of diagnoses that meet the high risk criteria for
colorectal cancer. This is not an all-inclusive list. There may be more instances of
conditions which may be coded and could be at the medical directors’ discretion.
• Personal History
o V10.05 - Personal history of malignant neoplasm of large intestine
o V10.06 - Personal history of malignant neoplasm of rectum, rectosigmoid
junction, and anus
• Chronic Digestive Disease Condition
o 555.0 - Regional enteritis of small intestine
o 555.1 - Regional enteritis of large intestine
o 555.2 - Regional enteritis of small intestine with large intestine
o 555.9 - Regional enteritis of unspecified site
o 556.0 - Ulcerative (chronic) enterocolitis
o 556.1 - Ulcerative (chronic) ileocolitis
o 556.2 - Ulcerative (chronic) proctitis
o 556.3 - Ulcerative (chronic) proctosigmoiditis
o 556.8 - Other ulcerative colitis
o 556.9 - Ulcerative colitis, unspecified (nonspecific PDX on the MCE)
• Inflammatory Bowel
o 558.2 - Toxic gastroenteritis and colitis
o 558.9 - Other and unspecified noninfectious gastroenteritis and colitis
C. Partial List of ICD-10-CM Codes Indicating High Risk (for Services after
Implementation of ICD-10)
Code
Description
K50.00
Crohn's disease of small intestine without complications
K50.011
Crohn's disease of small intestine with rectal bleeding
K50.012
Crohn's disease of small intestine with intestinal obstruction
K50.013
Crohn's disease of small intestine with fistula
K50.014
Crohn's disease of small intestine with abscess
K50.018
Crohn's disease of small intestine with other complication
K50.019
Crohn's disease of small intestine with unspecified complications
K50.10
Crohn's disease of large intestine without complications
K50.111
Crohn's disease of large intestine with rectal bleeding
Code
Description
K50.112
Crohn's disease of large intestine with intestinal obstruction
K50.113
Crohn's disease of large intestine with fistula
K50.114
Crohn's disease of large intestine with abscess
K50.118
Crohn's disease of large intestine with other complication
K50.119
Crohn's disease of large intestine with unspecified complications
K50.80
Crohn's disease of both small and large intestine without complications
K50.811
Crohn's disease of both small and large intestine with rectal bleeding
K50.812
Crohn's disease of both small and large intestine with intestinal obstruction
K50.813
Crohn's disease of both small and large intestine with fistula
K50.814
Crohn's disease of both small and large intestine with abscess
K50.818
Crohn's disease of both small and large intestine with other complication
K50.819
Crohn's disease of both small and large intestine with unspecified complications
K50.90
Crohn's disease, unspecified, without complications
K50.911
Crohn's disease, unspecified, with rectal bleeding
K50.912
Crohn's disease, unspecified, with intestinal obstruction
K50.913
Crohn's disease, unspecified, with fistula
K50.914
Crohn's disease, unspecified, with abscess
K50.918
Crohn's disease, unspecified, with other complication
K50.919
Crohn's disease, unspecified, with unspecified complications
K51.80
Other ulcerative colitis without complications
K51.80
Other ulcerative colitis without complications
K51.20
Ulcerative (chronic) proctitis without complications
K51.211
Ulcerative (chronic) proctitis with rectal bleeding
K51.212
Ulcerative (chronic) proctitis with intestinal obstruction
K51.213
Ulcerative (chronic) proctitis with fistula
K51.214
Ulcerative (chronic) proctitis with abscess
K51.218
Ulcerative (chronic) proctitis with other complication
K51.219
Ulcerative (chronic) proctitis with unspecified complications
Code
Description
K51.30
Ulcerative (chronic) rectosigmoiditis without complications
K51.311
Ulcerative (chronic) rectosigmoiditis with rectal bleeding
K51.312
Ulcerative (chronic) rectosigmoiditis with intestinal obstruction
K51.313
Ulcerative (chronic) rectosigmoiditis with fistula
K51.314
Ulcerative (chronic) rectosigmoiditis with abscess
K51.318
Ulcerative (chronic) rectosigmoiditis with other complication
K51.319
Ulcerative (chronic) rectosigmoiditis with unspecified complications
K51.80
Other ulcerative colitis without complications
K51.811
Other ulcerative colitis with rectal bleeding
K51.812
Other ulcerative colitis with intestinal obstruction
K51.813
Other ulcerative colitis with fistula
K51.814
Other ulcerative colitis with abscess
K51.818
Other ulcerative colitis with other complication
K51.819
Other ulcerative colitis with unspecified complications
K51.90
Ulcerative colitis, unspecified, without complications
K51.911
Ulcerative colitis, unspecified with rectal bleeding
K51.912
Ulcerative colitis, unspecified with intestinal obstruction
K51.913
Ulcerative colitis, unspecified with fistula
K51.914
Ulcerative colitis, unspecified with abscess
K51.918
Ulcerative colitis, unspecified with other complication
K51.919
Ulcerative colitis, unspecified with unspecified complications
K52.1
Toxic gastroenteritis and colitis
K52.89
Other specified noninfective gastroenteritis and colitis
K52.9
Noninfective gastroenteritis and colitis, unspecified
Z85.038
Personal history of other malignant neoplasm of large intestine
Z85.048
Personal history of other malignant neoplasm of rectum, rectosigmoid junction,
and anus
D12.6
Benign neoplasm of colon, unspecified
Code
Description
Z12.11
Encounter for screening for malignant neoplasm of colon
Z12.12
Encounter for screening for malignant neoplasm of rectum
Z15.09
Genetic susceptibility to other malignant neoplasm
Z80.0
Family history of malignant neoplasm of digestive organs
Z83.71
Family history of colonic polyps
280.2.4 - Determining Frequency Standards
(Rev. 1, 10-01-03)
B3-4180.4
To determine the 11, 23, 47, and 119-month periods, the count starts beginning with the
month after the month in which a previous test/procedure was performed.
EXAMPLE: The beneficiary received a fecal-occult blood test in January 2000. The
A/B MAC (B) starts its count beginning with February 2000. The beneficiary is eligible
to receive another blood test in January 2001 (the month after 11 full months have
passed).
280.2.5 - Noncovered Services
(Rev. 1, 10-01-03)
B3-4180.5
The following noncovered HCPCS codes are used to allow claims to be billed and denied
for beneficiaries who need a Medicare denial for other insurance purposes for the dates of
service indicated:
A. From January 1, 1998 Through June 30, 2001, Inclusive
Code G0121 (colorectal cancer screening; colonoscopy on an individual not meeting
criteria for high risk) should be used when this procedure is performed on a beneficiary
who does NOT meet the criteria for high risk. This service should be denied as
noncovered because it fails to meet the requirements of the benefit for these dates of
service. The beneficiary is liable for payment. Note that this code is a covered service for
dates of service on or after July 1, 2001.
B. On or After January 1, 1998
Code G0122 (colorectal cancer screening; barium enema) should be used when a
screening barium enema is performed NOT as an alternative to either a screening
colonoscopy (code G0105) or a screening flexible sigmoidoscopy (code G0104). This
service should be denied as noncovered because it fails to meet the requirements of the
benefit. The beneficiary is liable for payment.
280.3 - Screening Mammography
(Rev. 1, 10-01-03)
A3-3660.10, B3-4601.1
Section 4163 of the Omnibus Budget Reconciliation Act of 1990 added §1834(c) of the
Act to provide for Part B coverage of mammography screening performed on or after
January 1, 1991. The term “screening mammography” means a radiologic procedure
provided to an asymptomatic woman for the purpose of early detection of breast cancer
and includes a physician’s interpretation of the results of the procedure. Unlike
diagnostic mammographies, there do not need to be signs, symptoms, or history of breast
disease in order for the exam to be covered.
A doctor’s prescription or referral is not necessary for the procedure to be covered.
Payment may be made for a screening mammography furnished to a woman at her direct
request, and based on a woman’s age and statutory frequency parameter.
Section 4101 of the Balanced Budget Act (BBA) of 1997 provides for annual screening
mammographies for women over 39 and waives the Part B deductible. Coverage applies
as follows:
Age Screening Period
Less than 35
years old
No payment may be made for a screening mammography performed on
a woman under 35 years of age.
35-39 (Baseline). Pay for only one screening mammography performed on a
woman between her 35th and 40th birthday.
Over age 39 For a woman over 39, pay for a screening mammography performed
after 11 full months have passed following the month in which the last
screening mammography was performed.
To determine the 11-month period, A/B MACs (A) and (B) start counting beginning with
the month after the month in which a previous screening mammography was performed.
EXAMPLE: If Mrs. Smith received a screening mammography examination in January
1998, begin counting the next month (February 1998) until 11 months have elapsed.
Payment can be made for another screening mammography in January 1999.
See the Medicare Claims Processing Manual, Chapter 18, “Preventive and Screening
Services,” §30, for billing and payment instructions.
280.4 - Screening Pap Smears
(Rev. 194, Issued: 09-03-14, Effective: Upon Implementation of ICD-10,
Implementation: Upon Implementation of ICD-10)
Effective, January 1, 1998, §4102 of the Balanced Budget Act (BBA) of 1997 (P.L. 105-
33) amended §1861(nn) of the Act (42 USC 1395X(nn)) to include coverage every 3
years for a screening Pap smear or more frequent coverage for women:
1. At high risk for cervical or vaginal cancer; or
2. Of childbearing age who have had a Pap smear during any of the preceding 3 years
indicating the presence of cervical or vaginal cancer or other abnormality.
Effective July 1, 2001, the Consolidated Appropriations Act of 2001 (P.L. 106-554)
modifies §1861(nn) to provide Medicare coverage for biennial screening Pap smears.
Specifications for frequency limitations are defined below.
For claims with dates of service from January 1, 1998, through June 30, 2001, screening
Pap smears are covered when ordered and collected by a doctor of medicine or
osteopathy (as defined in §1861(r)(1) of the Act), or other authorized practitioner (e.g., a
certified nurse midwife, physician assistant, nurse practitioner, or clinical nurse specialist,
who is authorized under State law to perform the examination) under one of the following
conditions.
The beneficiary has not had a screening Pap smear test during the preceding 3 years (i.e.,
35 months have passed following the month that the woman had the last covered Pap
smear – ICD-9-CM code V76.2 or ICD-10 code Z112.4 is used to indicate special
screening for malignant neoplasm, cervix); or
There is evidence (on the basis of her medical history or other findings) that she is of
childbearing age and has had an examination that indicated the presence of cervical or
vaginal cancer or other abnormalities during any of the preceding 3 years; and at least 11
months have passed following the month that the last covered Pap smear was performed;
or
She is at high risk of developing cervical or vaginal cancer – ICD-9-CM code V15.89,
other specified personal history presenting hazards to health) or as applicable, ICD-10
code Z77.21, Z77.22, Z77.9, Z91.89, OR Z92.89 and at least 11 months have passed
following the month that the last covered screening Pap smear was performed. The high
risk factors for cervical and vaginal cancer are:
Cervical Cancer High Risk Factors
Early onset of sexual activity (under 16 years of age);
Multiple sexual partners (five or more in a lifetime);
History of a sexually transmitted disease (including HIV infection); and
Fewer than three negative or any Pap smears within the previous 7 years.
Vaginal Cancer High Risk Factors
The DES (diethylstilbestrol) - exposed daughters of women who took DES during
pregnancy.
The term “woman of childbearing age” means a woman who is premenopausal, and has
been determined by a physician, or qualified practitioner, to be of childbearing age, based
on her medical history or other findings. Payment is not made for a screening Pap smear
for women at high risk or who qualify for coverage under the childbearing provision
more frequently than once every 11 months after the month that the last screening Pap
smear covered by Medicare was performed.
B. For Claims with Dates of Service on or After July 1, 2001
When the beneficiary does not qualify for a more frequently performed screening Pap
smear as noted in items 1 and 2 above, contractors pay for the screening Pap smear only
after at least 23 months have passed following the month during which the beneficiary
received her last covered screening Pap smear. All other coverage and payment
requirements remain the same.
See the Medicare Claims Processing Manual, Chapter 18, “Preventive and Screening
Services,” for billing procedures.
280.5 – Annual Wellness Visit (AWV) Providing Personalized
Prevention Plan Services (PPPS)
(Rev. 170, Issued: 05-10-13, Effective: 01-01-12, Medicare Coverage of the Annual
Wellness Visit (AWV); 01-01-13- Medicare Coverage of Hepatitis B Vaccine,
Implementation: 06-10-13)
A. General
Pursuant to section 4103 of the Affordable Care Act of 2010 (the ACA), the Centers for
Medicare & Medicaid Services (CMS) amended section 42 CFR 411.15(a)(1) and 42
CFR 411.15(k)(15) (list of examples of routine physical examinations excluded from
coverage), effective for services furnished on or after January 1, 2011. This expanded
coverage, as established at 42 CFR 410.15, is subject to certain eligibility and other
limitations that allow payment for an annual wellness visit (AWV) providing
personalized prevention plan services (PPPS), when performed by a health professional
(as defined in this section), for an individual who is no longer within 12 months after the
effective date of his/her first Medicare Part B coverage period, and has not received
either an initial preventive physical examination (IPPE) or an AWV within the past 12
months. Medicare coinsurance and Part B deductibles do not apply.
The AWV will include the establishment of, or update to, the individual’s medical/family
history, measurement of his/her height, weight, body-mass index (BMI) or waist
circumference, and blood pressure (BP), with the goal of health promotion and disease
detection and encouraging patients to obtain the screening and preventive services that
may already be covered and paid for under Medicare Part B. Definitions relative to the
AWV are included below.
Coverage is available for an AWV that meets the following requirements:
1. It is performed by a health professional; and,
2. It is furnished to an eligible beneficiary who is no longer within 12 months
after the effective date of his/her first Medicare Part B coverage period, and
he/she has not received either an IPPE or an AWV providing PPPS within the past
12 months.
Sections 4103 and 4104 of the ACA also provide for a waiver of the Medicare
coinsurance and Part B deductible requirements for an AWV effective for services
furnished on or after January 1, 2011.
B. Definitions Relative to the AWV:
Detection of any cognitive impairment: The assessment of an individual’s cognitive
function by direct observation, with due consideration of information obtained by way of
patient reports, concerns raised by family members, friends, caretakers, or others.
Eligible beneficiary: An individual who is no longer within 12 months after the effective
date of his/her first Medicare Part B coverage period and who has not received either an
IPPE or an AWV providing PPPS within the past 12 months.
Establishment of, or an update to, the individual’s medical/family history: At a
minimum, the collection and documentation of the following:
a. Past medical and surgical history, including experiences with illnesses, hospital
stays, operations, allergies, injuries, and treatments.
b. Use or exposure to medications and supplements, including calcium and
vitamins.
c. Medical events in the beneficiary’s parents and any siblings and children,
including diseases that may be hereditary or place the individual at increased risk.
First AWV providing PPPS: The provision of the following services to an eligible
beneficiary by a health professional that include, and take into account the results of, a
health risk assessment as those terms are defined in this section:
a. Review (and administration if needed) of a health risk assessment (as defined
in this section).
b. Establishment of an individual’s medical/family history.
c. Establishment of a list of current providers and suppliers that are regularly
involved in providing medical care to the individual.
d. Measurement of an individual’s height, weight, BMI (or waist circumference,
if appropriate), BP, and other routine measurements as deemed appropriate, based
on the beneficiary’s medical/family history.
e. Detection of any cognitive impairment that the individual may have as defined
in this section.
f. Review of the individual’s potential (risk factors) for depression, including
current or past experiences with depression or other mood disorders, based on the
use of an appropriate screening instrument for persons without a current diagnosis
of depression, which the health professional may select from various available
standardized screening tests designed for this purpose and recognized by national
medical professional organizations.
g. Review of the individual’s functional ability and level of safety based on direct
observation, or the use of appropriate screening questions or a screening
questionnaire, which the health professional may select from various available
screening questions or standardized questionnaires designed for this purpose and
recognized by national professional medical organizations.
h. Establishment of the following:
(1) A written screening schedule for the individual, such as a checklist for the
next 5 to 10 years, as appropriate, based on recommendations of the United
States Preventive Services Task Force (USPSTF) and the Advisory
Committee on Immunization Practices (ACIP), and the individual’s health risk
assessment (as that term is defined in this section), the individual’s health
status, screening history, and age-appropriate preventive services covered by
Medicare.
(2) A list of risk factors and conditions for which primary, secondary, or
tertiary interventions are recommended or are underway for the individual,
including any mental health conditions or any such risk factors or conditions
that have been identified through an IPPE, and a list of treatment options and
their associated risks and benefits.
i. Furnishing of personalized health advice to the individual and a referral, as
appropriate, to health education or preventive counseling services or programs
aimed at reducing identified risk factors and improving self-management, or
community-based lifestyle interventions to reduce health risks and promote self-
management and wellness, including weight loss, physical activity, smoking
cessation, fall prevention, and nutrition.
j. Any other element determined appropriate through the National Coverage
Determination (NCD) process.
Health professional:
a. A physician who is a doctor of medicine or osteopathy (as defined in section
1861(r)(1) of the Social Security Act (the Act); or,
b. A physician assistant, nurse practitioner, or clinical nurse specialist (as defined
in section 1861(aa)(5) of the Act); or,
c. A medical professional (including a health educator, registered dietitian, or
nutrition professional or other licensed practitioner) or a team of such medical
professionals, working under the direct supervision (as defined in 42CFR
410.32(b)(3)(ii)) of a physician as defined in this section.
Health Risk Assessment means, for the purposes of the annual wellness visit, an
evaluation tool that meets the following criteria:
a. collects self-reported information about the beneficiary.
b. can be administered independently by the beneficiary or administered by a
health professional prior to or as part of the AWV encounter.
c. is appropriately tailored to and takes into account the communication needs of
underserved populations, persons with limited English proficiency, and persons
with health literacy needs.
d. takes no more than 20 minutes to complete.
e. addresses, at a minimum, the following topics:
1. demographic data, including but not limited to age, gender, race, and
ethnicity.
2. self assessment of health status, frailty, and physical functioning.
3. psychosocial risks, including but not limited to, depression/life satisfaction,
stress, anger, loneliness/social isolation, pain, and fatigue.
4. Behavioral risks, including but not limited to, tobacco use, physical
activity, nutrition and oral health, alcohol consumption, sexual health, motor
vehicle safety (seat belt use), and home safety.
5. Activities of daily living (ADLs), including but not limited to, dressing,
feeding, toileting, grooming, physical ambulation (including balance/risk of
falls), and bathing.
6. Instrumental activities of daily living (IADLs), including but not limited to,
shopping, food preparation, using the telephone, housekeeping, laundry, mode
of transportation, responsibility for own medications, and ability to handle
finances.
Review of the individual’s functional ability and level of safety: At a minimum,
includes assessment of the following topics:
a. Hearing impairment,
b. Ability to successfully perform activities of daily living,
c. Fall risk, and,
d. Home safety.
Subsequent AWV providing PPPS: The provision of the following services to an
eligible beneficiary by a health professional that include, and take into account the results
of an updated health risk assessment, as those terms are defined in this section:
a. Review (and administration if needed) of an updated health risk assessment (as
defined in this section).
b. An update of the individual’s medical/family history.
c. An update of the list of current providers and suppliers that are regularly
involved in providing medical care to the individual, as that list was developed for
the first AWV providing PPPS or the previous subsequent AWV providing PPPS.
d. Measurement of an individual’s weight (or waist circumference), BP, and
other routine measurements as deemed appropriate, based on the individual’s
medical/family history.
e. Detection of any cognitive impairment that the individual may have as defined
in this section.
f. An update to the following:
(1) The written screening schedule for the individual as that schedule is
defined in this section, that was developed at the first AWV providing PPPS,
and,
(2) The list of risk factors and conditions for which primary, secondary, or
tertiary interventions are recommended or are under way for the individual, as
that list was developed at the first AWV providing PPPS or the previous
subsequent AWV providing PPPS.
g. Furnishing of personalized health advice to the individual and a referral, as
appropriate, to health education or preventive counseling services or programs as
that advice and related services are defined for the first AWV providing PPPS.
h. Any other element determined appropriate by the Secretary through the NCD
process.
See Pub. 100-04, Medicare Claims Processing Manual, chapter 18, section 140, for
detailed claims processing and billing instructions.
280.5.1 – Advance Care Planning (ACP) Furnished as an Optional
Element with an Annual Wellness Visit (AWV) Upon Agreement with
the Patient
(Rev. 216 Issued: 12-22-15, Effective: 01-01-16, Implementation: 01-04-16)
Beginning in CY 2016, CMS will treat an AWV and voluntary ACP that are furnished on
the same day and by the same provider as a preventive service. Voluntary ACP services,
upon agreement with the patient, will be an optional element of the AWV. (See section
1861(hhh)(2)(G) of the Act.) When ACP services are furnished as a part of an AWV,
according to sections 1833(a)(1) and 1833(b)(10) of the Act, the coinsurance and
deductible are waived.
Voluntary advance care planning means the face-to-face service between a physician (or
other qualified health care professional) and the patient discussing advance directives,
with or without completing relevant legal forms. An advance directive is a document
appointing an agent and/or recording the wishes of a patient pertaining to his/her medical
treatment at a future time should he/she lack decisional capacity at that time.
See Pub. 100-04, Medicare Claims Processing Manual, chapter 18, section 140.8 for
claims processing and billing instructions.
290 - Foot Care
(Rev. 1, 10-01-03)
A3-3158, B3-2323, HO-260.9, B3-4120.1
A. Treatment of Subluxation of Foot
Subluxations of the foot are defined as partial dislocations or displacements of joint
surfaces, tendons ligaments, or muscles of the foot. Surgical or nonsurgical treatments
undertaken for the sole purpose of correcting a subluxated structure in the foot as an
isolated entity are not covered.
However, medical or surgical treatment of subluxation of the ankle joint (talo-crural
joint) is covered. In addition, reasonable and necessary medical or surgical services,
diagnosis, or treatment for medical conditions that have resulted from or are associated
with partial displacement of structures is covered. For example, if a patient has
osteoarthritis that has resulted in a partial displacement of joints in the foot, and the
primary treatment is for the osteoarthritis, coverage is provided.
B. Exclusions from Coverage
The following foot care services are generally excluded from coverage under both Part A
and Part B. (See §290.F and §290.G for instructions on applying foot care exclusions.)
1. Treatment of Flat Foot
The term “flat foot” is defined as a condition in which one or more arches of the foot
have flattened out. Services or devices directed toward the care or correction of such
conditions, including the prescription of supportive devices, are not covered.
2. Routine Foot Care
Except as provided above, routine foot care is excluded from coverage. Services that
normally are considered routine and not covered by Medicare include the following:
• The cutting or removal of corns and calluses;
• The trimming, cutting, clipping, or debriding of nails; and
• Other hygienic and preventive maintenance care, such as cleaning and soaking
the feet, the use of skin creams to maintain skin tone of either ambulatory or
bedfast patients, and any other service performed in the absence of localized
illness, injury, or symptoms involving the foot.
3. Supportive Devices for Feet
Orthopedic shoes and other supportive devices for the feet generally are not covered.
However, this exclusion does not apply to such a shoe if it is an integral part of a leg
brace, and its expense is included as part of the cost of the brace. Also, this exclusion
does not apply to therapeutic shoes furnished to diabetics.
C. Exceptions to Routine Foot Care Exclusion
1. Necessary and Integral Part of Otherwise Covered Services
In certain circumstances, services ordinarily considered to be routine may be covered if
they are performed as a necessary and integral part of otherwise covered services, such as
diagnosis and treatment of ulcers, wounds, or infections.
2. Treatment of Warts on Foot
The treatment of warts (including plantar warts) on the foot is covered to the same extent
as services provided for the treatment of warts located elsewhere on the body.
3. Presence of Systemic Condition
The presence of a systemic condition such as metabolic, neurologic, or peripheral
vascular disease may require scrupulous foot care by a professional that in the absence of
such condition(s) would be considered routine (and, therefore, excluded from coverage).
Accordingly, foot care that would otherwise be considered routine may be covered when
systemic condition(s) result in severe circulatory embarrassment or areas of diminished
sensation in the individual’s legs or feet. (See subsection A.)
In these instances, certain foot care procedures that otherwise are considered routine (e.g.,
cutting or removing corns and calluses, or trimming, cutting, clipping, or debriding nails)
may pose a hazard when performed by a nonprofessional person on patients with such
systemic conditions. (See §290.G for procedural instructions.)
4. Mycotic Nails
In the absence of a systemic condition, treatment of mycotic nails may be covered.
The treatment of mycotic nails for an ambulatory patient is covered only when the
physician attending the patient’s mycotic condition documents that (1) there is clinical
evidence of mycosis of the toenail, and (2) the patient has marked limitation of
ambulation, pain, or secondary infection resulting from the thickening and dystrophy of
the infected toenail plate.
The treatment of mycotic nails for a nonambulatory patient is covered only when the
physician attending the patient’s mycotic condition documents that (1) there is clinical
evidence of mycosis of the toenail, and (2) the patient suffers from pain or secondary
infection resulting from the thickening and dystrophy of the infected toenail plate.
For the purpose of these requirements, documentation means any written information that
is required by the A/B MAC (B) in order for services to be covered. Thus, the
information submitted with claims must be substantiated by information found in the
patient’s medical record. Any information, including that contained in a form letter, used
for documentation purposes is subject to A/B MAC (B) verification in order to ensure
that the information adequately justifies coverage of the treatment of mycotic nails.
D. Systemic Conditions That Might Justify Coverage
Although not intended as a comprehensive list, the following metabolic, neurologic, and
peripheral vascular diseases (with synonyms in parentheses) most commonly represent
the underlying conditions that might justify coverage for routine foot care.
Diabetes mellitus *
Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive
peripheral arteriosclerosis)
Buerger’s disease (thromboangiitis obliterans)
Chronic thrombophlebitis *
Peripheral neuropathies involving the feet -
Associated with malnutrition and vitamin deficiency *
• Malnutrition (general, pellagra)
• Alcoholism
• Malabsorption (celiac disease, tropical sprue)
• Pernicious anemia
Associated with carcinoma *
Associated with diabetes mellitus *
Associated with drugs and toxins *
Associated with multiple sclerosis *
Associated with uremia (chronic renal disease) *
Associated with traumatic injury
Associated with leprosy or neurosyphilis
Associated with hereditary disorders
• Hereditary sensory radicular neuropathy
• Angiokeratoma corporis diffusum (Fabry’s)
• Amyloid neuropathy
When the patient’s condition is one of those designated by an asterisk (*), routine
procedures are covered only if the patient is under the active care of a doctor of medicine
or osteopathy who documents the condition.
E. Supportive Devices for Feet
Orthopedic shoes and other supportive devices for the feet generally are not covered.
However, this exclusion does not apply to such a shoe if it is an integral part of a leg
brace, and its expense is included as part of the cost of the brace. Also, this exclusion
does not apply to therapeutic shoes furnished to diabetics.
F. Presumption of Coverage
In evaluating whether the routine services can be reimbursed, a presumption of coverage
may be made where the evidence available discloses certain physical and/or clinical
findings consistent with the diagnosis and indicative of severe peripheral involvement.
For purposes of applying this presumption the following findings are pertinent:
Class A Findings
Nontraumatic amputation of foot or integral skeletal portion thereof.
Class B Findings
Absent posterior tibial pulse;
Advanced trophic changes as: hair growth (decrease or absence) nail changes
(thickening) pigmentary changes (discoloration) skin texture (thin, shiny) skin
color (rubor or redness) (Three required); and
Absent dorsalis pedis pulse.
Class C Findings
Claudication;
Temperature changes (e.g., cold feet);
Edema;
Paresthesias (abnormal spontaneous sensations in the feet); and
Burning.
The presumption of coverage may be applied when the physician rendering the routine
foot care has identified:
1. A Class A finding;
2. Two of the Class B findings; or
3. One Class B and two Class C findings.
Cases evidencing findings falling short of these alternatives may involve podiatric
treatment that may constitute covered care and should be reviewed by the intermediary’s
medical staff and developed as necessary.
For purposes of applying the coverage presumption where the routine services have been
rendered by a podiatrist, the A/B MAC (B) may deem the active care requirement met if
the claim or other evidence available discloses that the patient has seen an M.D. or D.O.
for treatment and/or evaluation of the complicating disease process during the 6-month
period prior to the rendition of the routine-type services. The A/B MAC (A) may also
accept the podiatrist’s statement that the diagnosing and treating M.D. or D.O. also
concurs with the podiatrist’s findings as to the severity of the peripheral involvement
indicated.
Services ordinarily considered routine might also be covered if they are performed as a
necessary and integral part of otherwise covered services, such as diagnosis and treatment
of diabetic ulcers, wounds, and infections.
G. Application of Foot Care Exclusions to Physician’s Services
The exclusion of foot care is determined by the nature of the service. Thus, payment for
an excluded service should be denied whether performed by a podiatrist, osteopath, or a
doctor of medicine, and without regard to the difficulty or complexity of the procedure.
When an itemized bill shows both covered services and noncovered services not
integrally related to the covered service, the portion of charges attributable to the
noncovered services should be denied. (For example, if an itemized bill shows surgery
for an ingrown toenail and also removal of calluses not necessary for the performance of
toe surgery, any additional charge attributable to removal of the calluses should be
denied.)
In reviewing claims involving foot care, the A/B MAC (B) should be alert to the
following exceptional situations:
1. Payment may be made for incidental noncovered services performed as a
necessary and integral part of, and secondary to, a covered procedure. For
example, if trimming of toenails is required for application of a cast to a fractured
foot, the A/B MAC (B) need not allocate and deny a portion of the charge for the
trimming of the nails. However, a separately itemized charge for such excluded
service should be disallowed. When the primary procedure is covered the
administration of anesthesia necessary for the performance of such procedure is
also covered.
2. Payment may be made for initial diagnostic services performed in connection
with a specific symptom or complaint if it seems likely that its treatment would be
covered even though the resulting diagnosis may be one requiring only
noncovered care.
The name of the M.D. or D.O. who diagnosed the complicating condition must be
submitted with the claim. In those cases, where active care is required, the approximate
date the beneficiary was last seen by such physician must also be indicated.
NOTE: Section 939 of P.L. 96-499 removed “warts” from the routine foot care
exclusion effective July 1, 1981.
Relatively few claims for routine-type care are anticipated considering the severity of
conditions contemplated as the basis for this exception. Claims for this type of foot care
should not be paid in the absence of convincing evidence that nonprofessional
performance of the service would have been hazardous for the beneficiary because of an
underlying systemic disease. The mere statement of a diagnosis such as those mentioned
in §D above does not of itself indicate the severity of the condition. Where development
is indicated to verify diagnosis and/or severity the A/B MAC (B) should follow existing
claims processing practices, which may include review of A/B MAC (B)’s history and
medical consultation as well as physician contacts.
The rules in §290.F concerning presumption of coverage also apply.
Codes and policies for routine foot care and supportive devices for the feet are not
exclusively for the use of podiatrists. These codes must be used to report foot care
services regardless of the specialty of the physician who furnishes the services. A/B
MACs (B) must instruct physicians to use the most appropriate code available when
billing for routine foot care.
300 - Diabetes Self-Management Training Services
(Rev. 72, Issued: 05-25-07; Effective: 07-01-07; Implementation: 07-02-07)
Section 4105 of the Balanced Budget Act of 1997 permits Medicare coverage of diabetes
self-management training (DSMT) services when these services are furnished by a
certified provider who meets certain quality standards. This program is intended to
educate beneficiaries in the successful self-management of diabetes. The program
includes instructions in self-monitoring of blood glucose; education about diet and
exercise; an insulin treatment plan developed specifically for the patient who is insulin-
dependent; and motivation for patients to use the skills for self-management.
Diabetes self-management training services may be covered by Medicare only if the
treating physician or treating qualified non-physician practitioner who is managing the
beneficiary’s diabetic condition certifies that such services are needed. The referring
physician or qualified non-physician practitioner must maintain the plan of care in the
beneficiary’s medical record and documentation substantiating the need for training on an
individual basis when group training is typically covered, if so ordered. The order must
also include a statement signed by the physician that the service is needed as well as the
following:
• The number of initial or follow-up hours ordered (the physician can order less
than 10 hours of training);
• The topics to be covered in training (initial training hours can be used for the
full initial training program or specific areas such as nutrition or insulin training);
and
• A determination that the beneficiary should receive individual or group
training.
The provider of the service must maintain documentation in a file that includes the
original order from the physician and any special conditions noted by the physician.
When the training under the order is changed, the training order/referral must be signed
by the physician or qualified non-physician practitioner treating the beneficiary and
maintained in the beneficiary’s file in the DSMT’s program records.
NOTE: All entities billing for DSMT under the fee-for-service payment system or other
payment systems must meet all national coverage requirements.
300.1 - Beneficiaries Eligible for Coverage and Definition of Diabetes
(Rev. 13, 05-13-04)
Medicare Part B covers 10 hours of initial training for a beneficiary who has been
diagnosed with diabetes.
Diabetes is diabetes mellitus, a condition of abnormal glucose metabolism diagnosed
using the following criteria;
• a fasting blood sugar greater than or equal to 126 mg/dL on two different
occasions;
• a 2 hour post-glucose challenge greater than or equal to 200 mg/dL on 2 different
occasions; or
o a random glucose test over 200 mg/dL for a person with symptoms of
uncontrolled diabetes.
Documentation that the beneficiary is diabetic is maintained in the beneficiary’s medical
record.
Beneficiaries are eligible to receive follow-up training each calendar year following the
year in which they have been certified as requiring initial training or they may receive
follow-up training when ordered even if Medicare does not have documentation that
initial training has been received. In that instance, contractors shall not deny the follow-
up service even though there is no initial training recorded.
300.2 - Certified Providers
(Rev. 109; Issued: 08-07-09; Effective Date: 03-30-09; Implementation Date: 09-
08-09)
A designated certified provider bills for DSMT provided by an accredited DSMT
program. Certified providers must submit a copy of their accreditation certificate to the
contractor. The statute states that a “certified provider” is a physician or other individual
or entity designated by the Secretary that, in addition to providing outpatient self-
management training services, provides other items and services for which payment may
be made under title XVIII, and meets certain quality standards. The CMS is designating
all providers and suppliers that bill Medicare for other individual services such as
hospital outpatient departments, renal dialysis facilities, physicians and durable medical
equipment suppliers as certified. All suppliers/providers who may bill for other Medicare
services or items and who represent a DSMT program that is accredited as meeting
quality standards can bill and receive payment for the entire DSMT program. Registered
dietitians are eligible to bill on behalf of an entire DSMT program on or after January 1,
2002, as long as the provider has obtained a Medicare provider number. A dietitian may
not be the sole provider of the DSMT service. There is an exception for rural areas. In a
rural area, an individual who is qualified as a registered dietitian and as a certified
diabetic educator who is currently certified by an organization approved by CMS may
furnish training and is deemed to meet the multidisciplinary team requirement.
The CMS will not reimburse services on a fee-for-service basis rendered to a beneficiary
under Part A.
NOTE: While separate payment is not made for this service to Rural Health Clinics
(RHCs), the service is covered but is considered included in the all-inclusive encounter
rate. Effective January 1, 2006, payment for DSMT provided in a Federally Qualified
Health Clinic (FQHC) that meets all of the requirements identified in Pub. 100-04,
chapter 18, section 120 may be made in addition to one other visit the beneficiary had
during the same day.
All DSMT programs must be accredited as meeting quality standards by a CMS approved
national accreditation organization. Currently, CMS recognizes the American Diabetes
Association, American Association of Diabetes Educators and the Indian Health Service
as approved national accreditation organizations. Programs without accreditation by a
CMS-approved national accreditation organization are not covered. Certified providers
may be asked to submit updated accreditation documents at any time or to submit
outcome data to an organization designated by CMS.
Enrollment of DMEPOS Suppliers
The DMEPOS suppliers are reimbursed for diabetes training through A/B MACs (B). In
order to file claims for DSMT, a DMEPOS supplier must be enrolled in the Medicare
program with the National Supplier Clearinghouse (NSC). The supplier must also meet
the quality standards of a CMS-approved national accreditation organization as stated
above. DMEPOS suppliers must obtain a provider number from the A/B MAC (B) in
order to bill for DSMT.
The A/B MAC (B) requires a completed Form CMS-855, along with an accreditation
certificate as part of the provider application process. After it has been determined that
the quality standards are met, a billing number is assigned to the supplier. Once a
supplier has received a National Provider Identification (NPI) number, the supplier can
begin receiving reimbursement for this service.
A/B MACs (B) should contact the National Supplier Clearinghouse (NSC) according to
the instruction in Pub 100-08, the Medicare Program Integrity Manual, Chapter 10,
“Healthcare Provider/Supplier Enrollment,” to verify an applicant is currently enrolled
and eligible to receive direct payment from the Medicare program.
The applicant is assigned specialty 87.
Any DMEPOS supplier that has its billing privileges deactivated or revoked by the NSC
will also have the billing number deactivated by the A/B MAC (B).
300.3 - Frequency of Training
(Rev. 72, Issued: 05-25-07; Effective: 07-01-07; Implementation: 07-02-07)
A - Initial Training
The initial year for DSMT is the 12 month period following the initial date.
Medicare will cover initial training that meets the following conditions:
• Is furnished to a beneficiary who has not previously received initial or follow-up
training under HCPCS codes G0108 or G0109;
• Is furnished within a continuous 12-month period;
• Does not exceed a total of 10 hours* (the 10 hours of training can be done in any
combination of 1/2 hour increments);
• With the exception of 1 hour of individual training, training is usually furnished
in a group setting, which can contain other patients besides Medicare
beneficiaries, and;
• One hour of individual training may be used for any part of the training including
insulin training.
* When a claim contains a DSMT HCPCS code and the associated units cause the total
time for the DSMT initial year to exceed '10' hours, a CWF error will set.
B - Follow-Up Training
Medicare covers follow-up training under the following conditions:
• No more than 2 hours individual or group training per beneficiary per year;
• Group training consists of 2 to 20 individuals who need not all be Medicare
beneficiaries;
• Follow-up training for subsequent years is based on a 12 month calendar after
completion of the full 10 hours of initial training;
• Follow-up training is furnished in increments of no less than one-half hour*; and
• The physician (or qualified non-physician practitioner) treating the beneficiary
must document in the beneficiary's medical record that the beneficiary is a
diabetic.
*When a claim contains a DSMT HCPCS code and the associated units cause the
total time for any follow-up year to exceed 2 hours, a CWF error will set.
300.4 - Coverage Requirements for Individual Training
(Rev. 72, Issued: 05-25-07; Effective: 07-01-07; Implementation: 07-02-07)
Medicare covers training on an individual basis for a Medicare beneficiary under any of
the following conditions:
• No group session is available within 2 months of the date the training is ordered;
• The beneficiary’s physician (or qualified non-physician practitioner) documents
in the beneficiary’s medical record that the beneficiary has special needs resulting
from conditions, such as severe vision, hearing or language limitations or other
such special conditions as identified by the treating physician or non-physician
practitioner, that will hinder effective participation in a group training session; or
• The physician orders additional insulin training.
• The need for individual training must be identified by the physician or non-
physician practitioner in the referral.
NOTE: If individual training has been provided to a Medicare beneficiary and
subsequently the A/B MAC (A) or (B) determines that training should have been
provided in a group, A/B MACs (A) and (B) down-code the reimbursement from
individual to the group level and provider education would be the appropriate
actions instead of denying the service as billed.
300.4.1 – Incident-To Provision
(Rev. 13, 05-13-04)
The “incident to” requirements of section 1861(s)(2)(A) of the Social Security Act do not
apply to DSMT services. Section 1861 (s)(2)(S) of the Act authorizes DSMT in a stand
alone provision. DSMT services are covered only if the physician or qualified non-
physician practitioner who is managing the beneficiary’s diabetic condition certifies that
such services are needed and refers the patient to the DSMT program. The referral must
be done under a comprehensive plan of care related to the beneficiary’s diabetic
condition. Training may be furnished by a physician, individual, or entity that meets the
following conditions:
• Furnishes other services for which direct Medicare payment may be made;
• May properly receive Medicare payment under 42CFR 424.73 or 424.80
which set forth prohibitions on assignment and reassignment of claims;
• Submits necessary documentation to, and is accredited by, an accreditation
organization approved by CMS under 42CFR 410.142 to meet one of the sets
of quality standards described in 42 CFR 410.144; and
Provides documentation to CMS, as requested, including diabetes outcome
measurements set forth at CFR 410.146.
Any certified providers or suppliers that provide other individual items or services under
Medicare that meet CMS’s quality standards and meet the conditions for CMS approval
pursuant to 42 CFR 410.145, may receive reimbursement for diabetes training. Entities
are more likely than individuals to bill for DSMT services. These certified providers
must be currently receiving payment for other Medicare services.
300.5 - Payment for DSMT
(Rev. 72, Issued: 05-25-07; Effective: 07-01-07; Implementation: 07-02-07)
Payment for DSMT may only be made to any provider that bills Medicare for other
individual Medicare services and may be made only for training sessions actually
attended by the beneficiary and documented on attendance sheets.
See Pub. 100-04, chapter 18, section 120 for specific payment information for physicians
and all provider types.
300.5.1 - Special Claims Processing Instructions for A/B MACs (A)
(Rev. 24, Issued: 10-29-04, Effective: 01-01-05, Implementation: 01-03-05)
• Coding and Payment Requirements
The provider bills for DSMT on Form CMS-1450 or its electronic equivalent.
The cost of the service is billed under revenue code 942 in FL 42 “Revenue
Code.” The provider will report HCPCS codes G0108 or G0109 in FL 44
“HCPCS/Rates.” The definition of the HCPCS code used should be entered
in FL 43 “Description.”
• Applicable Bill Types
The appropriate bill types are 12x, 22x, 13x, 34x (can be billed if service is
outside of the treatment plan), 72x, 74x, 75x, 83x and 85x.
310 – Kidney Disease Patient Education Services
(Rev. 117; Issued: 12-18-09; Effective Date: 01-01-10; Implementation Date: 04-
05-10)
By definition, chronic kidney disease (CKD) is kidney damage for 3 months or longer,
regardless of the cause of kidney damage. CKD typically evolves over a long period of
time and patients may not have symptoms until significant, possibly irreversible, damage
has been done. Complications can develop from kidneys that do not function properly,
such as high blood pressure, anemia, and weak bones. When CKD progresses, it may
lead to kidney failure, which requires artificial means to perform kidney functions
(dialysis) or a kidney transplant to maintain life.
Patients can be classified into 5 stages based on their glomerular filtration rate (GFR,
how quickly blood is filtered through the kidneys), with stage I having kidney damage
with normal or increased GFR to stage V with kidney failure, also called end-stage renal
disease (ESRD). Once patients with CKD are identified, treatment is available to help
prevent complications of decreased kidney function, slow the progression of kidney
disease, and reduce the risk of other diseases such as heart disease.
Beneficiaries with CKD may benefit from kidney disease education (KDE) interventions
due to the large amount of medical information that could affect patient outcomes,
including the increasing emphasis on self-care and patients’ desire for informed,
autonomous decision-making. Pre-dialysis education can help patients achieve better
understanding of their illness, dialysis modality options, and may help delay the need for
dialysis. Education interventions should be patient-centered, encourage collaboration,
offer support to the patient, and be delivered consistently.
Effective for claims with dates of service on and after January 1, 2010, Section 152(b) of
the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) covers
KDE services under Medicare Part B. KDE services are designed to provide
beneficiaries with Stage IV CKD comprehensive information regarding: the management
of comorbidities, including delaying the need for dialysis; prevention of uremic
complications; all therapeutic options (each option for renal replacement therapy, dialysis
access options, and transplantation); ensuring that the beneficiary has opportunities to
actively participate in his/her choice of therapy; and that the services be tailored to meet
the beneficiary’s needs.
Regulations for KDE services were established at 42 CFR 410.48. Claims processing
instructions and billing requirements can be found in Pub. 100-04, Medicare Claims
Processing Manual, Chapter 32 – Billing Requirements for Special Services, Section 20.
310.1 - Beneficiaries Eligible for Coverage
(Rev. 117; Issued: 12-18-09; Effective Date: 01-01-10; Implementation Date: 04-
05-10)
Medicare Part B covers outpatient, face-to-face KDE services for a beneficiary that:
• is diagnosed with Stage IV CKD, using the Modification of Diet in Renal Disease
(MDRD) Study formula (severe decrease in GFR, GFR value of 15-29
mL/min/1.73 m
2
), and
• obtains a referral from the physician managing the beneficiary’s kidney condition.
The referral should be documented in the beneficiary’s medical records.
310.2 - Qualified Person
(Rev. 117; Issued: 12-18-09; Effective Date: 01-01-10; Implementation Date: 04-
05-10)
Medicare Part B covers KDE services provided by a ‘qualified person,’ meaning a:
• physician (as defined in section 30 of this chapter),
• physician assistant, nurse practitioner, or clinical nurse specialist (as defined in
sections 190, 200, and 210 of this chapter),
• hospital, critical access hospital (CAH), skilled nursing facility (SNF),
comprehensive outpatient rehabilitation facility (CORF), home health agency
(HHA), or hospice, if the KDE services are provided in a rural area (using the
actual geographic location core based statistical area (CBSA) to identify facilities
located in rural areas), or
• hospital or CAH that is treated as being rural (was reclassified from urban to rural
status per 42 CFR 412.103).
NOTE: The “incident to” requirements at section 1861(s)(2)(A) of the Social Security
Act (the Act) do not apply to KDE services.
The following providers are not ‘qualified persons’ and are excluded from furnishing
KDE services:
• A hospital, CAH, SNF, CORF, HHA, or hospice located outside of a rural area
(using the actual geographic location CBSA to identify facilities located outside
of a rural area), unless the services are furnished by a hospital or CAH that is
treated as being in a rural area; and
• Renal dialysis facilities.
310.3 - Limitations for Coverage
(Rev. 194, Issued: 09-03-14, Effective: Upon Implementation of ICD-10,
Implementation: Upon Implementation of ICD-10)
Medicare Part B covers KDE services:
• Up to six (6) sessions as a beneficiary lifetime maximum. A session is 1 hour. In
order to bill for a session, a session must be at least 31 minutes in duration. A
session that lasts at least 31 minutes, but less than 1 hour still constitutes 1
session.
• On an individual basis or in group settings; if the services are provided in a group
setting, a group consists of 2 to 20 individuals who need not all be Medicare
beneficiaries.
NOTE: Two HCPCS codes were created for this benefit and one or the other must be
present, along with the appropriate ICD diagnosis codes.
The diagnosis codes are:
• ICD-9-CM - code 585.4 (chronic kidney disease, Stage IV (severe)), or
• ICD-10-CM - code N18.4 (chronic kidney disease, Stage IV).
The HCPCS codes are:
• G0420: Face-to-face educational services related to the care of chronic kidney
disease; individual, per session, per one hour
• G0421: Face-to-face educational services related to the care of chronic kidney
disease; group, per session, per one hour
310.4 – Standards for Content
(Rev. 117; Issued: 12-18-09; Effective Date: 01-01-10; Implementation Date: 04-
05-10)
Medicare Part B covers KDE services, provided by a qualified person, which provide
comprehensive information regarding:
A. The management of comorbidities, including delaying the need for dialysis, which
includes, but is not limited to, the following topics:
• Prevention and treatment of cardiovascular disease,
• Prevention and treatment of diabetes,
• Hypertension management,
• Anemia management,
• Bone disease and disorders of calcium and phosphorus metabolism management,
• Symptomatic neuropathy management, and
• Impairments in functioning and well-being.
B. Prevention of uremic complications, which includes, but is not limited to, the
following topics:
• Information on how the kidneys work and what happens when the kidneys fail,
• Understanding if remaining kidney function can be protected, preventing disease
progression, and realistic chances of survival,
• Diet and fluid restrictions, and
• Medication review, including how each medication works, possible side effects
and minimization of side effects, the importance of compliance, and informed
decision making if the patient decides not to take a specific drug.
C. Therapeutic options, treatment modalities and settings, advantages and
disadvantages of each treatment option, and how the treatments replace the
kidney, including, but not limited to, the following topics:
• Hemodialysis, both at home and in-facility;
• Peritoneal dialysis (PD), including intermittent PD, continuous ambulatory PD,
and continuous cycling PD, both at home and in-facility;
• All dialysis access options for hemodialysis and peritoneal dialysis; and
• Transplantation.
D. Opportunities for beneficiaries to actively participate in the choice of therapy and
be tailored to meet the needs of the individual beneficiary involved, which
includes, but is not limited to, the following topics:
• Physical symptoms,
• Impact on family and social life,
• Exercise,
• The right to refuse treatment,
• Impact on work and finances,
• The meaning of test results, and
• Psychological impact.
310.5 - Outcomes Assessment
(Rev. 117; Issued: 12-18-09; Effective Date: 01-01-10; Implementation Date: 04-
05-10)
Qualified persons that provide KDE services must develop outcomes assessments that are
designed to measure beneficiary knowledge about CKD and its treatment. The
assessment must be administered to the beneficiary during a KDE session, and be made
available to the Centers for Medicare & Medicaid Services (CMS) upon request. The
outcomes assessments serve to assist KDE educators and CMS in improving subsequent
KDE programs, patient understanding, and assess program effectiveness of:
• Preparing the beneficiary to make informed decisions about their healthcare
options related to CKD, and
• Meeting the communication needs of underserved populations, including persons
with disabilities, persons with limited English proficiency, and persons with
health literacy needs.
320 - Home Infusion Therapy Services
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
Effective January 1, 2021, section 5012 of the 21st Century Cures Act (Pub. L. 114–255),
which added sections 1861(s)(2)(GG) and 1861(iii) of the Act, established a new
Medicare home infusion therapy services benefit. Section 1861(iii) of the Act establishes
certain provisions related to home infusion therapy with respect to the requirements that
must be met for Medicare payment to be made to qualified home infusion therapy
suppliers. These provisions serve as the basis for determining the scope of the home
infusion drugs eligible for coverage of home infusion therapy services; outline
beneficiary qualifications and plan of care requirements; and establish who can bill for
payment under the benefit.
The Medicare home infusion therapy services benefit covers the professional services,
including nursing services, furnished in accordance with the plan of care, patient training
and education (not otherwise covered under the durable medical equipment (DME)
benefit), remote monitoring, and monitoring services for the provision of home infusion
drugs, furnished by a qualified home infusion therapy supplier in the individual’s home.
The home infusion therapy services are covered for the safe and effective administration
of certain drugs and biologicals administered intravenously, or subcutaneously for an
administration period of 15 minutes or more, in the home of an individual, through a
pump that is an item of DME. The infusion pump and supplies (including home infusion
drugs) will continue to be covered under the DME benefit.
320.1 - General Requirements for Payment of Home Infusion Therapy
Services
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
The home infusion therapy services must be furnished to an eligible beneficiary by, or
under arrangement with, a qualified home infusion therapy supplier that meets the health
and safety standards for qualified home infusion therapy suppliers at 42 CFR 486 Subpart
I, and all requirements set forth in 42 CFR 414 Subpart P.
As a condition for payment, qualified home infusion therapy suppliers must ensure that a
beneficiary meets certain eligibility criteria for coverage of services, as well as ensure
that certain plan of care requirements are met.
320.2 - Home Infusion Therapy Services Benefit is Separate from DME
Benefit
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
In order to avoid making duplicative payment, the training and education furnished under
the DME benefit is explicitly excluded from the home infusion therapy services payment.
The home infusion therapy services benefit provides a separate payment in addition to the
existing payment made under the DME benefit, thus explicitly and separately paying for
the home infusion therapy services. Therefore, the professional services covered under
the DME benefit are not covered under the home infusion therapy services benefit. While
the two benefits exist in tandem, the services are unique to each benefit and billed and
paid for under separate payment systems.
For DME infusion pumps, the DME benefit covers the infusion drugs and other supplies
and services necessary for the effective use of the pump, but does not explicitly require or
pay separately for any associated skilled professional services beyond what is necessary
for teaching the patient and/or caregiver how to operate the equipment in order to
administer the infusion safely and effectively in the patient’s home (42 CFR
424.57(c)(12)).
The home infusion therapy services benefit is a separate payment in addition to the
existing payment for the DME external infusion pump, supplies (including the furnishing
of the home infusion drug), and related services covered under the DME benefit. Further
billing information can be found in Publication 100-04, Chapter 32, Section 411.
320.3 - Qualified Home Infusion Therapy Suppliers
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
Section 1861(iii)(3)(D)(i) of the Act defines a qualified home infusion therapy supplier as
a pharmacy, physician, or other provider of services or supplier licensed by the State in
which the pharmacy, physician, or provider of services or supplier furnishes items or
services.
The qualified home infusion therapy supplier must:
A. Furnish home infusion therapy services to individuals with acute or chronic
conditions requiring administration of home infusion drugs;
B. Ensure the safe and effective provision and administration of home infusion
therapy services on a 7-day-a-week, 24-hour a-day basis;
C. Be accredited by an organization designated by the Secretary; and meet such other
requirements as the Secretary determines appropriate.
The supplier may subcontract with a pharmacy, physician, other qualified supplier or
provider of medical services, in order to meet these requirements. Additionally, section
1861(u) of the Act defines “provider of services” to mean a hospital, critical access
hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home
health agency, hospice program, or, for purposes of sections 1814(g) and 1835(e) of the
Act, a fund. Therefore, any of the previously noted entities who meet the Medicare
accreditation requirements for home infusion therapy suppliers is eligible to enroll as a
qualified home infusion therapy supplier.
In the case that a home health agency also becomes accredited as a home infusion therapy
supplier, the HHA would continue to meet the requirements under the Home Health
Conditions of Participation (CoPs) as well as the home infusion therapy supplier
requirements as set out in 42 CFR 486 Subpart I, of which DME services, including
pharmacy services associated with the preparation and dispensing of home infusion drugs
are not included.
The qualified home infusion therapy supplier is not required to furnish the infusion pump,
home infusion drug, or related pharmacy services. The infusion pump, drug, other
supplies, and the services required to furnish these items (that is, the compounding and
dispensing of the drug) remain covered under the DME benefit. Pharmacy services,
remote or otherwise, furnished by a Medicare enrolled DMEPOS supplier, associated
with the preparation and dispensing of home infusion drugs are covered under the DME
benefit and are not part of this specific home infusion therapy services benefit.
320.4 - Patient Eligibility for Home Infusion Therapy
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
To be eligible to receive home infusion therapy services under the home infusion therapy
benefit, a beneficiary must have Medicare Part B and meet each of the following
requirements:
A. The beneficiary must be under the care of an applicable provider, as defined in
section 1861(iii)(3)(A) of the Act as a physician, nurse practitioner, or physician
assistant.
B. The beneficiary must be under a physician-established plan of care that meets the
requirements specified in 42 CFR 414.1515 and 42 CFR 486.520, as described in
section 320.5 of this chapter.
Home infusion services must be furnished in the patient’s home, which means the place
of residence as defined for purposes of section 1861(n) of the Act used as the home of an
individual, including an institution that is used as a home (excluding hospitals, critical
access hospitals, and skilled nursing facilities as defined in section 1819(a)(1) of the Act).
320.4.1 - Home Infusion Therapy Services for Homebound Patients
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
A beneficiary is not required to be homebound in order to receive home infusion therapy
services. However, there may be instances where a beneficiary under a home health plan
of care also requires home infusion therapy services.
If a patient receiving home infusion therapy is also under a home health plan of care, and
receives a visit that is unrelated to home infusion therapy, then payment for the home
health visit would be covered under the Home Health Prospective Payment System (HH
PPS) and billed on the home health claim.
When the home health agency furnishing home health services is also enrolled as the
qualified home infusion therapy supplier furnishing home infusion therapy services, and a
home visit is exclusively for the purpose of furnishing items and services related to the
administration of the home infusion drug, the home health agency would submit a home
infusion therapy services claim under the home infusion therapy services benefit.
If the home visit includes the provision of other home health services in addition to, and
separate from, home infusion therapy services, the home health agency would submit
both a home health claim under the HH PPS and a home infusion therapy services claim
under the home infusion therapy services benefit. However, the agency must separate the
time spent furnishing services covered under the HH PPS from the time spent furnishing
services covered under the home infusion therapy services benefit.
If the qualified home infusion therapy supplier is not the same entity as the home health
agency furnishing the home health services, the home health agency would continue to
bill under the HH PPS on the home health claim, and the qualified home infusion therapy
supplier would bill for the services related to the administration of the home infusion
drugs on the home infusion therapy services claim.
320.5 - Plan of Care Requirements
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
In accordance with section 1861(iii)(1)(B) of the Act, the beneficiary must be under a
plan of care, established by a physician (defined at section 1861(r)(1) of the Act as a
doctor of medicine or osteopathy legally authorized to practice medicine and surgery by
the State in which he performs such function or action), prescribing the type, amount, and
duration of infusion therapy services that are to be furnished, and periodically reviewed,
in coordination with the furnishing of home infusion drugs under Part B.
The qualified home infusion therapy supplier must ensure that all patients are under the
care of an applicable provider and have a physician-established plan of care that meets all
of the following requirements:
A. Plan of Care Content - The plan of care must prescribe the type, amount, and
duration of the home infusion therapy services that are to be furnished. The plan
of care would also include the specific medication, the prescribed dosage and
frequency as well as the professional services to be utilized for treatment.
B. Physician's Orders - The physician's orders for services in the plan of care must
specify at what frequency the services will be furnished, as well as the discipline
that will furnish the ordered professional services. Orders for care may indicate a
specific range in frequency of visits to ensure that the most appropriate level of
services is furnished. The plan of care would specify the care and services
necessary to meet the patient specific needs
C. Physician’s Signature - The plan of care must be signed and dated by the ordering
physician prior to submitting a claim for payment. The ordering physician must
sign and date the plan of care upon any changes to the plan of care.
D. Periodic Review - The plan of care for each patient must be periodically reviewed
by the physician. The expectation is that the physician is active in the patient’s
care and can make appropriate decisions related to the course of therapy if
changes are necessary in regards to the progress and goals of the patient’s
infusion therapy.
320.5.1 - Notification of Available Infusion Therapy Options
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
Section 1834(u)(6) of the Act requires that prior to the furnishing of home infusion
therapy to an individual, the physician who establishes the plan of care shall provide
notification of the options available (such as home, physician’s office, hospital outpatient
department) for the furnishing of infusion therapy. Physicians are expected to routinely
discuss these infusion therapy options with their patients and annotate these discussions
in their patients’ medical records prior to establishing a home infusion therapy plan of
care.
320.5.2 - Plan of Care Periodic Review and Provider Coordination
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
Depending on patient acuity or the complexity of the drug administration, certain
infusions may require more training and education, especially those that require special
handling or pre-or post-infusion protocols. The home infusion process typically requires
coordination among multiple entities, including patients, physicians, hospital discharge
planners, health plans, home infusion pharmacies, and, if applicable, home health
agencies.
For payment purposes, all services billed to Medicare by the qualified home infusion
therapy supplier must be reflected in the plan of care, which is required to be established
and reviewed by the physician. Section 1861(iii)(1)(B) of the Act requires that the plan
of care be established and periodically reviewed by a physician in coordination with the
furnishing of home infusion drugs. This means that the plan of care must be established
and reviewed by a physician in consultation with the suppliers responsible for furnishing
the home infusion drug and related services. “The statute does not specify that the home
infusion plan of care must be established by the same physician who orders the DME and
infusion drugs and signs the detailed written order. It is expected that in most cases the
physician ordering the home infusion therapy services is the same physician ordering the
DME and the infusion drug, however, this may not always be the case. Furthermore, if a
hospital-based physician initially orders the infusion drug and/or the home infusion
therapy services for a patient, they will likely not continue to follow the patient after
discharge; however, in order for the patient to continue to receive home infusion therapy
services, that patient must be under a physician-established plan of care that is reviewed
periodically. Any updates to this plan of care would not likely be made by the hospital-
based physician, rather by whichever physician that takes over the patient’s care after
hospital discharge. In this case, a physician serving as the “applicable provider” as
described in section 320.4 could also be the “ordering physician” as mentioned in section
320.5. Regardless of whether the physician ordering the home infusion drug is the same
physician ordering and updating the home infusion therapy services, there must be care
coordination among all entities in order to meet the plan of care requirements.”
The physician establishing the plan of care is required to consult with the DME supplier
and the home infusion therapy supplier. In order to ensure that home infusion therapy is
safe and effective and stays current throughout the course of treatment, the physician who
orders the home infusion therapy services must review the plan of care on a regular basis
in coordination with the DME supplier. The DME supplier is also required to consult
with the physician prescribing the infusion drug as needed to confirm the drug order and
any necessary changes, refinements, or additional evaluation to the prescribed equipment
item(s), and/or service(s).
The plan of care plays an integral part in care coordination between providers,
particularly when the physician ordering the home infusion drug is not the same
physician establishing the home infusion therapy services plan of care. Coordination
between the physician ordering the home infusion drug, the physician establishing the
plan of care for the home infusion therapy services, and the DME supplier furnishing the
home infusion drug is imperative in providing safe and effective home infusion therapy.
Coordination would likely include review of the patient assessment and evaluation,
including interpretation of lab results as they pertain to changes in medication type, dose,
or frequency. A current home infusion therapy services plan of care is essential in order
to ensure that the qualified home infusion therapy supplier is providing the appropriate
professional services, including patient monitoring, to ensure that medication
administration is safe and effective.
As coordination is required between the DME supplier responsible for furnishing the
infusion drug, and both the physician establishing the home infusion therapy services
plan of care and the prescriber of the home infusion drug, all entities are expected to be
involved in this care coordination process.
320.6 - Professional Services, Including Nursing Services, for Home
Infusion Therapy
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
In order to ensure that patients have access to expert clinical knowledge and advice to
safely and effectively manage all aspects of treatment, especially in the event of an urgent
or emergent infusion-related situation, the qualified home infusion therapy supplier must
provide the following services on a 7-day-a-week, 24-hour-a-day basis, in accordance
with the plan of care:
A. Professional services, including nursing services.
B. Patient training and education not otherwise paid for as durable medical
equipment as described in 42 CFR 424.57(c)(12).
C. Remote monitoring and monitoring services for the provision of home infusion
therapy services and home infusion drugs.
D. All home infusion therapy suppliers must provide home infusion therapy services
in accordance with nationally recognized standards of practice, and in accordance
with all applicable state and federal laws and regulations. This could include the
applicable provisions in the Federal Food, Drug, and Cosmetic Act.
Professional services, including nursing services, are skilled services which may be
necessary for an individual patient or particular therapy or course of treatment, as
determined by the physician responsible for the plan of care. The skilled services
provided on an infusion drug administration calendar day must be so inherently complex
that they can only be safely and effectively performed by, or under the supervision of,
professional or technical personnel. Additionally, the skilled professional must only
furnish services within the scope of his/her practice.
No payment may be made under Medicare Part A or Part B for any expenses incurred for
items or services which are not reasonable and necessary for the diagnosis or treatment of
illness or injury or to improve the functioning of a malformed body member.
The services provided under the home infusion therapy services benefit are distinct from
those required and paid under the DME benefit and may include, but are not limited to,
the following:
- Training and education on care and maintenance of vascular access devices:
o Hygiene education
o Instruction on what to do in the event of a dislodgement or occlusion
o Education on signs and symptoms of infection
o Teaching and training on flushing and locking the catheter
- Dressing changes and site care
- Patient assessment and evaluation:
o Review history and assess current physical and mental status, including
obtaining vital signs
o Assess any adverse effects or infusion complications
o Evaluate family and caregiver support
o Review prescribed treatment and any concurrent oral and/or over-the-
counter treatments
o Obtain blood for lab-work
- Medication and disease management education:
o Instruction on self-monitoring
o Education on lifestyle and nutritional modifications
o Education regarding drug mechanism of action, side effects, interactions
with other medications, adverse and infusion-related reactions
o Education regarding therapy goals and progress
o Instruction on administering pre-medications and inspection of medication
prior to use
o Education regarding household and contact precautions and/or spills
- Remote monitoring services
- Monitoring services:
o Communicate with patient regarding changes in condition and treatment
plan
o Monitor patient response to therapy
o Assess compliance
Some of these services are further described in sections 320.6.1 and 320.6.2 of this
chapter.
320.6.1 - Home Infusion Therapy Services Training and Education
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
Consistent with section 1861(iii)(2)(B) of the Act, qualified home infusion suppliers are
required to provide patient training and education, not otherwise paid for as durable
medical equipment, and as described in 42 CFR 424.57(c)(12). In addition, the patient
training and education requirements are consistent with standards that are already in
place, as established by the current accrediting organizations of home infusion therapy
suppliers. This is a best practice, as home infusion therapy may entail the use of
equipment and supplies with which patients’ may not be comfortable or familiar.
Hygiene Training and Maintenance of Vascular Access Devices
Many beneficiaries receiving home infusion therapy may have a unique need for a central
vascular access device (CVAD) that requires training and education regarding
maintenance and hygiene. This may include education regarding properly disinfecting
access points and connectors, dressing changes, and recommended actions in the event of
a dislodgement, occlusion, and signs of infection. This also includes teaching the patient
about flushing the CVAD after the infusion to ensure all of the medication has been
flushed through the tubing and catheter, and locking the catheter to prevent blood from
backing into the catheter and clotting. Education regarding specific techniques and
solutions (saline or heparin) may also be given to minimize catheter occlusion.
Medication and Disease Management
The qualified home infusion therapy supplier is responsible for ensuring the patient has
been properly educated about his/her disease, medication therapy, and lifestyle changes.
This could include self-monitoring instruction (nutrition, temperature, blood pressure,
heart rate, daily weight, abdominal girth measurement, edema, urine output) and
identification of complications or problems necessitating a patient call to the designated
infusion clinician (nurse, pharmacist, or physician), or emergency protocols if they arise.
The qualified home infusion therapy supplier should ensure the patient’s proper
understanding of the medication therapy including: drug, route of administration,
prescription (dosage, how often to administer, and duration of therapy), side effects and
interactions with other medications, adverse reactions to therapy, goals of therapy and
indications of progress. Lifestyle education regarding behavior and food/fluid
modifications/restrictions, symptom management, and infection control are also
important aspects of patient education.
While the durable medical equipment supplier is responsible for training the patient and
caregiver on the infusion pump operation, maintenance, and troubleshooting, the
qualified home infusion therapy supplier would be responsible for all other aspects of
medication administration. These services may include inspection of medications,
containers, and supplies prior to use; proper drug storage and disposal; hand hygiene and
aseptic technique; education on pre/post medication/hydration administration; and
training on medication preparation. Household precautions for chemotherapy drugs
including spills, handling body wastes, and physical contact precautions must also be
addressed.
Patient Assessment and Evaluation
Comprehensive patient assessment is imperative when providing home infusion therapy.
The home infusion therapy supplier may evaluate patient history, current physical and
mental status, lab reports, cognitive and psychosocial status, family/care-partner support,
prescribed treatment, concurrent oral prescriptions, and over-the-counter medications.
For patients receiving potentially life-long, continuous intravenous infusion therapy,
home infusion therapy suppliers can provide extensive support and education and address
necessary lifestyle changes and realistic expectations of life with an ambulatory pump.
320.6.2 - Remote Monitoring and Monitoring Services
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
Qualified home infusion therapy suppliers are required to ensure the safe and effective
provision and administration of home infusion therapy on a 7-day-a-week, 24-hour-a-day
basis. Monitoring the patient receiving infusion therapy in their home is an important
standard of practice that is an integral part of providing medical care to patients in their
home. The expectation is that home infusion therapy suppliers would provide ongoing
patient monitoring and continual reassessment of the patient to evaluate response to
treatment, drug complications, adverse reactions, and patient compliance.
The plan of care would indicate the need for routine monitoring and specify the interval
for evaluation and documentation of patient-reported response to therapy, any adverse
effects or infusion complications, verify pump rate, obtain blood work, and obtain any
necessary vital signs. Direct communication and coordination with the patient,
caregivers, and clinicians regarding any change in the patient’s condition is on-going so
that any adjustment to treatment is made as needed and in a timely fashion. This can be
done remotely or directly during in-home patient visits at specified intervals.
Remote monitoring may be performed through telephone or other electronic
communication, based on the plan of care and the patient’s preference of communication.
Remote monitoring may include the use of a telecommunications system through which
patients are monitored by electronic submission of self-obtained vital signs, such as
weight, blood pressure, and heart rate. The patient must be instructed on obtaining vital
signs and on self-monitoring equipment use. An off-site monitoring service may also be
utilized to communicate any abnormal results to the clinician for adjustments to the plan
of care as needed.
Qualified home infusion therapy suppliers may use all available remote monitoring
methods that are safe and appropriate for their patients and clinicians and as specified in
the plan of care as long as adequate security and privacy protections are utilized.
320.7 - Home Infusion Therapy Drugs
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
“Home infusion drugs” are defined as parenteral drugs and biologicals administered
intravenously, or subcutaneously for an administration period of 15 minutes or more, in
the home of an individual through a pump that is an item of DME covered under the
Medicare Part B DME benefit, pursuant to and the regulatory definition set out at 42 CFR
486 Subpart I and the statutory definition set out in section 1861(iii)(3)(C) of the Act, and
incorporated by cross reference at section 1834(u)(7)(A)(iii) of the Act.
Section 1861(iii)(3)(C) of the Act also states that such term “home infusion drugs” does
not include insulin pump systems or self-administered drugs or biologicals on a self-
administered drug exclusion list. See section 50.2 of this chapter for instructions
regarding the determination of self-administered drugs or biologicals.
See the Medicare Claims Processing Manual, Chapter 32, Section 411 for a list of drugs
and biologicals that meet the criteria of a home infusion drug. It is important to note that
this list is not static.
The home infusion drugs identified for coverage of home infusion therapy services are
paid under the DME benefit. The related pharmacy services, furnished by a Medicare
enrolled DMEPOS supplier, including the preparation and dispensing of home infusion
drugs, are also paid under the DME benefit and are not part of this specific home infusion
therapy services benefit.
320.7.1 - Determining Qualifying Home Infusion Drugs
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
In general, Medicare Part B covers a limited number of home infusion drugs through the
DME benefit if:
1. the drug is necessary for the effective use of an infusion pump classified as DME
and determined to be reasonable and necessary for administration of the drug; and
2. the drug being used with the pump is itself reasonable and necessary for the
treatment of an illness or injury.
Specifically, under this home infusion therapy services benefit, a home infusion drug
must require infusion through an external infusion pump that is covered under the DME
benefit. If the drug or biological can be infused through a disposable pump or by a
gravity drip, it does not meet this criterion.
Only certain types of infusion pumps are covered under the DME benefit. The Medicare
National Coverage Determinations Manual, Publication 100-03, Chapter 1, Section 280.1
describes the types of infusion pumps that are covered under the DME benefit. The DME
MACs then specify the details of which infusion drugs are covered with these pumps.
The drugs and biologicals identified in the DME Local Coverage Determination (LCD)
for External Infusion Pumps (L33794) qualify as home infusion drugs as long as they are
infused intravenously or subcutaneously over a period of 15 minutes or more, are not
classified as insulin for insulin pump use, and are not on a self-administered drug
exclusion list. These drugs continue to be paid for under the DME benefit as supply
drugs to the covered infusion pump. Any additional training and education services
needed for the patient to administer these drugs at home would be covered under this
home infusion therapy services benefit.
There are other infusion drugs covered under Part B that could potentially be added to the
DME LCD for External Infusion Pumps (L33794) and thus qualify for services under the
home infusion therapy services benefit. Allowing the DME MACs to maintain the list of
infusion drugs and biologicals ensures quarterly review of any and all medications that
meet the criteria for external infusion pumps, thus ensuring an up to date, inclusive
benefit.
320.8 - Payment for Home Infusion Therapy Services
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
A unit of single payment is made for items and services furnished by a qualified home
infusion therapy supplier per payment category for each infusion drug administration
calendar day. The single payment amount represents payment in full for all costs
associated with the furnishing of home infusion therapy services.
320.8.1 - Home Infusion Drug Payment Categories
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
Payment for home infusion therapy services is contingent upon a corresponding home
infusion drug being covered and paid for under the DME benefit. Therefore, home
infusion therapy suppliers must ensure that the appropriate drug is billed by the DME
supplier no more than 30 days prior to the home infusion therapy service visit.
Home infusion drugs are assigned to three payment categories, as determined by the
HCPCS J-code:
- Payment category 1 includes certain intravenous infusion drugs for therapy,
prophylaxis, or diagnosis, such as antifungals and antivirals, inotropic and
pulmonary hypertension drugs, pain management drugs, chelation drugs; but
excludes chemotherapy and other highly complex drugs or biologicals.
- Payment category 2 includes subcutaneous infusions for therapy or prophylaxis,
such as certain subcutaneous immunotherapy infusions.
- Payment category 3 includes intravenous chemotherapy infusions, including
certain chemotherapy drugs, and other highly complex drugs and biologicals.
Specific billing codes are associated with each of the three payment categories in order
for qualified home infusion therapy suppliers to bill Medicare for home infusion therapy
services on an infusion drug administration calendar day.
A unit of single payment is made for items and services furnished by a qualified home
infusion therapy supplier per payment category for each infusion drug administration
calendar day.
The J-codes for eligible home infusion drugs, the G-codes for the home infusion therapy
services, and billing instructions for home infusion therapy payments are found in the
Medicare Claims Processing Manual Chapter 32, Section 411.
320.8.2 - Infusion Drug Administration Calendar Day and Unit of Single
Payment
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
Section 1834(u)(7)(E)(i) of the Act states that payment to a qualified home infusion
therapy supplier for an “infusion drug administration calendar day” in the individual’s
home refers to payment only for the date on which professional services, as described in
section 1861(iii)(2)(A) of the Act, were furnished to administer such drugs to such
individual. This means the day on which home infusion therapy services are furnished by
a skilled professional in the individual's home on the day of infusion drug administration.
This includes all such drugs administered to such individual on such day.
A “single payment amount” for an infusion drug administration calendar day means that
all home infusion therapy services, which include professional services, including
nursing; training and education; remote monitoring; and monitoring, are built into the day
on which the services are furnished in the home and the drug is being administered. There
may be professional services furnished in the patient’s home that do not occur on a day
the drug is being administered, however, the home infusion therapy services payment is a
unit of single payment. In other words, payment for an infusion drug administration
calendar day is a bundled payment amount per visit in the patient’s home furnishing
services specifically related to the physical process by which the drug enters the patient’s
body. The home infusion therapy payment rates reflect the increased complexity of the
skilled professional services provided per payment category. The skilled services
provided on such day must be so inherently complex that they can only be safely and
effectively performed by, or under the supervision of, professional or technical personnel.
A unit of single payment is made for items and services furnished by a qualified home
infusion therapy supplier per payment category for each infusion drug administration
calendar day. Although the single payment covers both professional services under
section 1861(iii)(2)(A) and training and education, remote monitoring, and other
monitoring services under section 1861(iii)(2)(B), payment is only issued on days on
which professional services are provided in the patient’s home, by the qualified home
infusion therapy supplier.
The qualified home infusion therapy supplier must submit, in line-item detail on the
claim, an appropriate G-code for each infusion drug administration calendar day. The
claim should include the length of time, in 15-minute increments, for which professional
services were furnished. Billing instructions for home infusion therapy services are
found in the Medicare Claims Processing Manual Chapter 32 Section 411.
320.8.3 - Initial Visits and Subsequent Visits for Home Infusion Therapy
Services
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
The first visit furnished by a qualified home infusion therapy supplier to furnish services
in the patient’s home may be longer or more resource intensive than subsequent visits.
For each of the three payment categories listed in 320.8.1 of this chapter, the payment
amounts are set higher for the first visit by the qualified home infusion therapy supplier
to initiate the furnishing of home infusion therapy services in the patient's home and
lower for subsequent visits in the patient's home.
If a patient receiving home infusion therapy services is discharged from such services, in
order to bill a first visit again, the patient’s history must show a gap of more than 60 days
between home infusion therapy service visits. This means that upon re-admission, there
cannot be a G-code billed for this patient within the past 60 days, and the last G-code
billed for this patient must show that the patient had been discharged. A qualified home
infusion therapy supplier could bill the first visit payment amount on day 61 for a patient
who had previously been discharged from service.
The G-codes for the initial and subsequent home infusion therapy service visits, and
instructions for billing for home infusion therapy services payments are found in the
Medicare Claims Processing Manual Chapter 32 Section 411.
320.9 - Medical Review
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)
All payments under this benefit may be subject to a medical review adjustment reflecting
the following:
1. Beneficiary eligibility.
2. Plan of care requirements.
3. Medical necessity determinations.
330 – Marriage and Family Therapist (MFT) Services
(Rev. 12448; Issued:01-11-24, Effective: 01-01-24; Implementation: 02-12-24)
See the Medicare Claims Processing Manual Chapter 12, Physician/Nonphysician
Practitioners, §240, “Marriage and Family Therapist Services,” for payment requirements.
A. Marriage and Family Therapist Defined
§ 410.53 defines a “marriage and family therapist” as an individual who:
• Possesses a master's or doctor's degree which qualifies for licensure or
certification as a marriage and family therapist pursuant to State law of the
State in which such individual furnishes the services defined as marriage and
family therapist services;
• After obtaining such degree, has performed at least 2 years or 3,000 hours of
post master’s degree clinical supervised experience in marriage and family
therapy in an appropriate setting such as a hospital, SNF, private practice, or
clinic; and
• Is licensed or certified as a marriage and family therapist by the State in which
the services are performed.
B. Marriage and Family Therapist Services Defined
Section 1861(lll)(1) of the Act defines “marriage and family therapist services” as
services furnished by an MFT for the diagnosis and treatment of mental illnesses (other
than services furnished to an inpatient of a hospital), which the MFT is legally authorized
to perform under State law (or the State regulatory mechanism provided by State law) of
the State in which such services are furnished, as would otherwise be covered if furnished
by a physician or as an incident to a physician’s professional service.
C. Covered Services
Coverage is limited to the services a MFT is legally authorized to perform in
accordance with State law (or State regulatory mechanism established by State law).
The services of a MFT may be covered under Part B if they are:
•
The type of services for the diagnosis and treatment of mental illnesses that
are otherwise covered if furnished by a physician, or as incident to a
physician’s service. (See §30 for a description of physicians’ services and §70
of Pub 100-1, the Medicare General Information, Eligibility, and Entitlement
Manual, Chapter 5, for the definition of a physician.);
•
Performed by a person who meets the definition of a MFT (See subsection A.);
and
•
Not otherwise excluded from coverage.
A/B MACs (B) should become familiar with the State law or regulatory mechanism
governing a MFT’s scope of practice in their service area.
D. Noncovered Services
Services of a MFT are not covered when furnished to inpatients of a hospital. In
addition, MFT services are not covered if they are otherwise excluded from Medicare
coverage even though a MFT is authorized by State law to perform them. For
example, the Medicare law excludes from coverage services that are not “reasonable
and necessary for the diagnosis or treatment of an illness or injury or to improve the
functioning of a malformed body member.”
E. Assignment Requirement
Assignment is required.
340 - Mental Health Counselor (MHC) Services
(Rev. 12448; Issued:01-11-24, Effective: 01-01-24; Implementation: 02-12-24)
See the Medicare Claims Processing Manual Chapter 12, Physician/Nonphysician
Practitioners, §250, “Mental Health Counselor Services,” for payment requirements.
A. Mental Health Counselor Defined
§ 410.54 defines a “mental health counselor” as an individual who:
• Possesses a master's or doctor's degree which qualifies for licensure or
certification as a mental health counselor, clinical professional counselor,
professional counselor under the State law of the State in which such individual
furnishes the services defined as mental health counselor services;
• After obtaining such a degree, has performed at least 2 years or 3,000 hours of
post master’s degree clinical supervised experience in mental health counseling in
an appropriate setting such as a hospital, SNF, private practice, or clinic; and
• Is licensed or certified as a mental health counselor, clinical professional
counselor, professional counselor by the State in which the services are
performed.
B. Mental Health Counselor Services Defined
Section 1861(lll)(3) of the Act defines “mental health counselor services” as services
furnished by a mental health counselor (MHC) for the diagnosis and treatment of mental
illnesses (other than services furnished to an inpatient of a hospital), which the MHC is
legally authorized to perform under State law (or the State regulatory mechanism
provided by the State law) of the State in which such services are furnished, as would
otherwise be covered if furnished by a physician or as incident to a physician’s
professional service.
Additionally, to the extent that addiction counselors and alcohol and drug counselors
who furnish services for the diagnosis and treatment of mental illnesses, including
substance use disorders, meet all of the statutory and regulatory requirements
regarding education, clinical supervised experience, and State licensure for MHCs,
such counselors can enroll in Medicare as MHCs.
C. Covered Services
Coverage is limited to the services a MHC is legally authorized to perform
in accordance with State law (or State regulatory mechanism established
by State law). The services of a MHC may be covered under Part B if
they are:
a. The type of services for the diagnosis and treatment of mental
illnesses that are otherwise covered if furnished by a
physician, or as incident to a physician’s service. (See §30 for
a description of physicians’ services and §70 of Pub 100-1,
the Medicare General Information, Eligibility, and
Entitlement Manual, Chapter 5, for the definition of a
physician.);
b. Performed by a person who meets the definition of a MHC
(See subsection A.); and
c. Not otherwise excluded from coverage.
A/B MACs (B) should become familiar with the State law or regulatory
mechanism governing a MHC’s scope of practice in their service area.
D. Noncovered Services
Services of a MHC are not covered when furnished to inpatients of a
hospital. In addition, MHC services are not covered if they are otherwise
excluded from Medicare coverage even though a MHC is authorized by
State law to perform them. For example, the Medicare law excludes
from coverage services that are not “reasonable and necessary for the
diagnosis or treatment of an illness or injury or to improve the
functioning of a malformed body member.”
E. Assignment Requirement
Assignment is required.
Transmittals Issued for this Chapter
Rev # Issue Date Subject Impl Date CR#
R12684BP
06/13/2024
Manual Update Pub. 100-02
Medicare Benefit Policy, Chapter
15, Section 110.8 Durable Medical
Equipment, Prosthetics, Orthotics
and Supplies (DMEPOS) Benefit
Category Determinations
07/15/2024
13651
R12532BP
03/07/2024
Update to Pub. 100-02 Medicare
Benefit Policy Manual, Chapter 15,
Section 110.8 Durable Medical
Equipment Prosthetics Orthotics
and Supplies (DMEPOS) Benefit
Category Determinations and Add
Section 145 Lymphedema
Compression Treatment Items
05/06/2024
13526
R12497BP
02/08/2024
Pulmonary Rehabilitation, Cardiac
Rehabilitation and Intensive
Cardiac Rehabilitation
(PR/CR/ICR) Expansion of
Supervising Practitioners
03/12/2024
13513
R12448BP
01/11/2024
Updates to Medicare Benefit Policy
Manual and Medicare Claims
Processing Manual for Marriage
and Family Therapists (MFTs) and
Mental Health Counselors (MHCs)
02/12/2024
13469
R12425BP
12/21/2023
Enforcing Billing Requirements for
Intensive Outpatient Program (IOP)
Services with New Condition Code
92 - Additional Publication Update
01/02/2024 13496
R12352BP
11/08/2023 Manual Updates for Coverage of
Intravenous Immune Globulin
(IVIG) For Treatment of Primary
Immune Deficiency Diseases in the
Home
01/02/2024 13414
R12299BP
10/12/2023 An Omnibus CR to Implement
Policy Updates in the CY 2023 PFS
Final Rule, Including (1) Removal
11/13/2023 13017
Rev # Issue Date Subject Impl Date CR#
of Selected NCDs (NCD 160.22
Ambulatory EEG Monitoring), and,
(2) Expanding Coverage of
Colorectal Cancer Screening - Full
Agile Pilot CR
R12171BP
08/03/2023
Update to Pub. 100-02 Medicare
Benefit Policy, Chapter 15, Section
110.8 Durable Medical Equipment,
Prosthetics, Orthotics and Supplies
(DMEPOS) Benefit Category
Determinations
09/04/2023 13228
R11901BP
03/16/2023
Update to the Manual to Clarify
Supervision Requirements for
Diagnostic Tests
05/17/2023 13094
R11995BP
04/21/2023 Medicare Policy Updates for Dental
Services as Finalized in the
Calendar Year (CY) 2023
Physician Fee Schedule (MPFS)
Final Rule
05/12/2023 13181
R11905BP
03/16/2023
Revisions to Medicare Part B
Coverage of Pneumococcal
Vaccinations for the Medicare
Policy Manual Chapter 15, Section
50.4.4.2
04/17/2023 13118
R11865BP
02/16/2023 An Omnibus CR to Implement
Policy Updates in the CY 2023 PFS
Final Rule, Including (1) Removal
of Selected NCDs (NCD 160.22
Ambulatory EEG Monitoring), and,
(2) Expanding Coverage of
Colorectal Cancer Screening - Full
Agile Pilot CR - Rescinded and
Replaced by Transmittal 12299
02/27/2023 13017
R11824BP
01/27/2023
An Omnibus CR to Implement
Policy Updates in the CY 2023 PFS
Final Rule, Including (1) Removal
of Selected NCDs (NCD 160.22
02/27/2023 13017
Rev # Issue Date Subject Impl Date CR#
Ambulatory EEG Monitoring), and,
(2) Expanding Coverage of
Colorectal Cancer Screening - Full
Agile Pilot CR- Rescinded and
Replaced by Transmittal 11865
R11769BP
12/30/2022
Manual Update Pub. 100-02
Medicare Benefit Policy, Chapter
15, Section 110.8 Durable Medical
Equipment, Prosthetics, Orthotics
and Supplies (DMEPOS) Benefit
Category Determinations
01/31/2023 13029
R11771BP
12/30/2022 Internet-Only Manual (IOM)
Updates for Nurse Practitioners
(NPs) and Clinical Nurse
Specialists (CNSs)
01/31/2023 13029
R11764BP
12/22/2022 New Medicare Part B
Immunosuppressant Drug Benefit
(PBID) – Implementation
01/03/2023 12804
R11646BP
10/19/2022 New Medicare Part B
Immunosuppressant Drug Benefit
(PBID) – Implementation -
Rescinded and Replaced by
Transmittal 11764
01/03/2023 12804
07/28/2022 New Medicare Part B
Immunosuppressant Drug Benefit
(PBID) – Implementation
SENSITIVE/CONTROVERSIAL
DO NOT POST – Rescinded and
Replaced by Transmittal 11646
01/03/2023 12804
R11426BP 05/20/2022 An Omnibus CR Covering: (1)
Removal of Two National
Coverage Determination (NCDs),
(2) Updates to the Medical
Nutrition Therapy (MNT) Policy,
and (3) Updates to the Pulmonary
Rehabilitation (PR), Cardiac
07/05/2022 12613
Rev # Issue Date Subject Impl Date CR#
Rehabilitation (CR), and Intensive
Cardiac Rehabilitation (ICR)
Conditions of Coverage
R11399BP 05/04/2022 Revisions to Medicare Part B
Coverage of Pneumococcal
Vaccinations for the Medicare
Benefit Policy Manual Chapter 15,
Section 50.4.4.2
06/06/2022 12723
R11355BP 04/14/2022 Update to Publication 100-04,
Chapter 18 and Publication 100-02,
Chapter 15, Section to Add Data
Regarding Novel Coronavirus
(COVID-19) and its Administration
to Current Claims Processing
Requirements and Other General
Updates
05/06/2022 12634
R11288BP 03/04/2022 Internet-Only Manual Updates
(IOM) for Critical Care,
Split/Shared Evaluation and
Management Services, Teaching
Physicians, and Physician
Assistants
02/15/2022 12543
R11272BP 02/18/2022
An Omnibus CR Covering: (1)
Removal of Two National
Coverage Determination (NCDs),
(2) Updates to the Medical
Nutrition Therapy (MNT) Policy,
and (3) Updates to the Pulmonary
Rehabilitation (PR), Cardiac
Rehabilitation (CR), and Intensive
Cardiac Rehabilitation (ICR)
Conditions of Coverage- Rescinded
and replaced by transmittal 11426
07/05/2022 12613
R11181BP 01/14/2022 Internet-Only Manual Updates
(IOM) for Critical Care,
02/15/2022 12543
Rev # Issue Date Subject Impl Date CR#
Split/Shared Evaluation and
Management Services, Teaching
Physicians, and Physician
Assistants – Rescinded and
replaced by transmittal 11288
R10880BP 08/06/2021
Internet Only Manual Updates to
Pub. 100-01, 100-02, and 100-04 to
Implement Consolidated
Appropriations Act Changes and
Correct Errors and Omissions
(SNF)
11/08/2021 12009
R10573BP 03/24/2021 Update to Pulmonary
Rehabilitation (PR), Cardiac
Rehabilitation (CR) and Intensive
Cardiac Rehabilitation (ICR)
Program Manual Sections
04/26/2021 12115
R10639BP 03/12/2021 Update to the Manual for
Telephone Services, Physician
Assistant (PA) Supervision, and
Medical Record Documentation for
Part B Services
04/12/2021 11862
R10547BP 12/31/2020 Billing for Home Infusion Therapy
Services On or After January 1,
2021
01/04/2021 11880
R10463BP 11/13/2020 Billing for Home Infusion Therapy
Services On or After January 1,
2021 – Rescinded and replaced by
transmittal 10574
01/04/2021 11880
R10269BP 08/07/2020 Billing for Home Infusion Therapy
Services On or After January 1,
2021- Rescinded and replaced by
transmittal 10463
01/04/2021 11880
R259BP 07/12/2019 Update to Coverage of Intravenous
Immune Globulin for Treatment of
Primary Immune Deficiency
Diseases in the Home
08/13/2019 11295
Rev # Issue Date Subject Impl Date CR#
R256BP 02/01/2019 Update to Intensive Cardiac
Rehabilitation (ICR) Programs
03/19/2019 11117
R255BP
01/25/2019 Updates to Reflect Removal of
Functional Reporting Requirements
and Therapy Provisions of the
Bipartisan Budget Act of 2018
02/26/2019 11120
R251BP 11/30/2018 Revision of Definition of the
Physician Supervision of
Diagnostic Procedures,
Clarification of DSMT Telehealth
Services, and Establishing a
Modifier for Expanding the Use of
Telehealth for Individuals with
Stroke
01/02/2019 11043
R241BP 02/02/2018 New “K” Code for Therapeutic
Shoe Inserts
04/02/2018 10436
R235BP 06/09/2017 Removal of Contractor
Requirement to Submit Opt Out
Data into the Contractor Reporting
of Operational and Workload Data
(CROWD) System (Form 8)
07/11/2017 10121
R228BP 10/13/2016 Internet Only Manual Updates to
Pub. 100-01, 100-02 and 100-04 to
Correct Errors and Omissions
(SNF)
10/18/2016 9748
R227BP 09/16/2016 Internet Only Manual Updates to
Pub. 100-01, 100-02 and 100-04 to
Correct Errors and Omissions
(SNF) - Rescinded and replaced by
Transmittal 228
10/18/2016 9748
R222BP 05/13/2016 Revisions to Private
Contracting/Opt-Out Manual
Sections Due to the Medicare
Access and CHIP Reauthorization
Act of 2015 (MACRA)
08/15/2016 9616
Rev # Issue Date Subject Impl Date CR#
R221BP 03/11/2016 Telehealth Services 04/11/2016 9428
R216BP 12/22/2015 Advance Care Planning (ACP) as
an Optional Element of an Annual
Wellness Visit (AWV)
01/04/2016 9271
R212BP 11/06/2015 Update to the List of Compendia as
Authoritative Sources for Use in
the Determination of a “Medically-
Accepted Indication” of Drugs and
Biologicals Used Off-label in an
Anti-Cancer Chemotherapeutic
Regimen
02/10/2016 9386
R210BP 08/07/2015 Advance Care Planning (ACP) as
an Optional Element of an Annual
Wellness Visit (AWV) – Rescinded
and replaced by Transmittal 216
01/04/2016 9271
R206BP 04/10/2015 Private Contracting: Definition of
Emergency Care Services and
Appeals of Opt Out Determinations
07/13/2015 9116
R203BP 02/13/2015 Payment Repairs to Capped Rental
Equipment Prior to the End of the
13-Month Cap
07/06/2015 9062
R202BP 12/31/2014 Modifications to Medicare Part B
Coverage of Pneumococcal
Vaccinations
02/02/2015 9051
R196BP 10/17/2014 Medicare Coverage of Ultrasound
Screening for Abdominal Aortic
Aneurysms (AAA) and Screening
Fecal-Occult Blood Tests (FOBT)
11/18/2014 8881
R194BP 09/03/2014 Pub. 100-02 Language-Only
Update for ICD-10
Upon
Implementation
of ICD-10
8605
R193BP 08/29/2014 Cardiac Rehabilitation Programs
for Chronic Heart Failure
08/18/2014 8758
R192BP 08/01/2014 Clarification of the Confined to the
Home Definition in Chapter 15,
09/02/2014 8818
Rev # Issue Date Subject Impl Date CR#
Covered Medical and Other Health
Services, of the Medicare Benefit
Policy Manual
R191BP 07/18/2014 Cardiac Rehabilitation Programs
for Chronic Heart Failure –
Rescinded and replaced by
Transmittal 193
08/18/2014 8758
R186BP 04/16/2014 Clarification to Pub. 100-02,
Medicare Benefit Policy Manual
Regarding Antigens and Deletion
of Section 13.14 from Chapter 13
of Pub. 100-08, Medicare Program
Integrity Manual
05/12/2014 8665
R185BP 04/15/2014 Aprepitant for Chemotherapy
Induced Emesis
07/07/2014 8418
R184BP 04/11/2014 Clarification to Pub. 100-02,
Medicare Benefit Policy Manual
Regarding Antigens and Deletion
of Section 13.14 from Chapter 13
of Pub. 100-08, Medicare Program
Integrity Manual – Rescinded and
replaced by Transmittal 186
05/12/2014 8665
R182BP 03/21/1014 Implementing the Part B Inpatient
Payment Policies from CMS-1599-
F
04/21/2014 8666
R181BP 03/14/2014 Pub. 100-02 Language-Only
Update for ICD-10 – Rescinded
and replaced by Transmittal 194
10/01/2014 8605
R180BP 02/21/2014 Aprepitant for Chemotherapy
Induced Emesis – Rescinded and
replaced by Transmittal 185
07/07/2014 8418
R179BP 01/14/2014 Manual Updates to Clarify Skilled
Nursing Facility (SNF), Inpatient
Rehabilitation Facility (IRF), Home
Health (HH), and Outpatient (OPT)
Coverage Pursuant to Jimmo vs.
Sebelius
01/07/2014 8458
Rev # Issue Date Subject Impl Date CR#
R178BP 12/30/2013 Expansion of Medicare Telehealth
Services for CY 2014
01/06/2014 8553
R176BP 12/13/2013 Manual Updates to Clarify Skilled
Nursing Facility (SNF), Inpatient
Rehabilitation Facility (IRF), Home
Health (HH), and Outpatient (OPT)
Coverage Pursuant to Jimmo vs.
Sebelius – Rescinded and replaced
by Transmittal 179
01/07/2014 8458
R170BP 05/10/2013 Updates to Medicare Coverage of
Hepatitis B Vaccine and its
Administration and Medicare
Coverage of the Annual Wellness
Visit (AWV) Providing
Personalized Prevention Plan
Services (PPPS)
06/10/2013 8275
R167BP 02/06/2013 Expansion of Medicare Telehealth
Services for CY 2012
01/25/2013 7900
R165BP 12/21/2012 Implementing the Claims-Based
Data Collection Requirement for
Outpatient Therapy Services --
Section 3005(g) of the Middle
Class Tax Relief and Jobs Creation
Act (MCTRJCA) of 2012
01/07/2013 8005
R164BP 11/30/2012 Expansion of Medicare Telehealth
Services for CY 2012 - Rescinded
and replaced by Transmittal 167
01/07/2013 7900
R163BP 11/30/2012 Implementing the Claims-Based
Data Collection Requirement for
Outpatient Therapy Services --
Section 3005(g) of the Middle
Class Tax Relief and Jobs Creation
Act (MCTRJCA) of 2012 –
Rescinded and replaced by
Transmittal 165
01/07/2013 8005
R161BP 10/26/2012 Manual Updates to Clarify SNF
Claims Processing
04/01/2013 8044
Rev # Issue Date Subject Impl Date CR#
R160BP 10/26/2012 Effect of Beneficiary Agreements
Not to Use Medicare Coverage and
When Payment May be Made to a
Beneficiary for Service of an Opt-
Out Physician/Practitioner
01/28/2013 8100
R159BP 08/31/2012 Expansion of Medicare Telehealth
Services for CY 2012 Rescinded
and replaced by Transmittal 164
01/07/2013 7900
R158BP 08/24/2012 Implementing the Claims-Based
Data Collection Requirement for
Outpatient Therapy Services --
Section 3005(g) of the Middle
Class Tax Relief and Jobs Creation
Act (MCTRJCA) of 2012 –
Rescinded and replaced by
Transmittal 163
01/07/2013 8005
R157BP 06/08/2012 July 2012 Update of the Hospital
Outpatient Prospective Payment
System (OPPS)
07/02/2012 7847
R151BP 11/18/2011 Expansion of Medicare Telehealth
Services for CY 2012
01/03/2012 7504
R147BP 08/26/2011 Clarification of Evaluation and
Management Payment Policy
11/28/2011 7405
R146BP 08/12/2011 Expansion of Medicare Telehealth
Services for CY 2012 – Rescinded
and replaced by Transmittal 151
01/03/2012 7504
R145BP 07/08/2011 Influenza Virus Vaccine 08/08/2011 7453
R140BP 02/28/2011 Expansion of Medicare Telehealth
Services for CY 2011
01/03/2011 &
04/04/2011
7049
R138BP 02/15/2011 Annual Wellness Visit (AWV),
Including Personalized Prevention
Plan Services (PPPS)
04/04/2011 7079
R134BP 12/03/2010 Annual Wellness Visit (AWV),
Including Personalized Prevention
04/04/2011 7079
Rev # Issue Date Subject Impl Date CR#
Plan Services (PPPS) – Rescinded
and replaced by Transmittal 138
R132BP 09/03/2010 Revisions and Re-issuance of
Audiology Policies
09/30/2010 6447
R131BP 08/20/2010 Expansion of Medicare Telehealth
Services for CY 2011 – Rescinded
and replaced by Transmittal 140
01/03/2011 7049
R129BP 07/23/2010 Revisions and Re-issuance of
Audiology Policies - Rescinded and
replaced by Transmittal 132
08/11/2010 6447
R127BP 05/28/2010 Revisions and Re-issuance of
Audiology Policies - Rescinded and
replaced by Transmittal 129
07/28/2010 6447
R126BP 05/21/2010 Cardiac Rehabilitation and
Intensive Cardiac Rehabilitation
10042010 6850
R124BP 05/07/2010 Pulmonary Rehabilitation (PR)
Services
10/04/2010 6823
R123BP 04/30/2010 Determining Self-Administration of
Drug or Biological
07/30/2010 6950
R120BP 01/29/2010 Revision of Definition of
Compendia as Authoritative Source
for Use in the Determination of a
Medically-Accepted Indication of
Drugs/Biologicals Used Off-Label
in Anti-Cancer Chemotherapeutic
Regimens
03/01/2010 6806
R118BP 12/18/2009 Expansion of Telelhealth Services
for CY 2010
01/04/2010 6705
R117BP 12/18/2009 Coverage of Kidney Disease
Patient Education Services
04/05/2010 6557
R116BP 12/11/2009 January 2010 Update of the
Hospital Outpatient Prospective
Payment System (OPPS)
01/04/2010 6751
Rev # Issue Date Subject Impl Date CR#
R109BP 08/07/2009 Diabetes Self-Management
Training (DSMT) Certified
Diabetic Educator
09/08/2009 6510
R108BP 07/31/2009 New Reporting Requirements for
the Quarterly Opt Out Report in
Contractor Reporting of
Operational Workload Data
(CROWD)
01/04/2010 6562
R106BP 04/24/2009 Speech-Language Pathology
Practice Payment Policy
07/06/2009 6381
R105BP 04/24/2009 List of Medicare Telehealth
Services
05/26/2009 6458
R104BP 03/13/2009 April 2009 Update to the ASC
Payment System; Summary of
Payment Policy Changes/Manual
Revisions
04/06/2009 6424
R99BP 12/24/2008 Expansion of Medicare Telehealth
Services
01/05/2009 6130
R97BP 11/14/2008 Adding Certain Entities as
Originating Sites for Payment of
Telehealth Services-Section 149 of
the Medicare Improvements for
Patients and Providers Act of 2008
(MIPPA)
01/05/2009 6215
R96BP 10/24/2008 Compendia as Authoritative
Sources for Use in the
Determination of a “Medically
Accepted Indication” of Drugs and
Biologicals Used Off-Label in an
Anti-Cancer Chemotherapeutic
Regimen
11/25/2008 6191
R94BP 08/29/2008 Physician Signature Requirements
for Diagnostic Tests
09/30/2008 6100
R93BP 07/25/2008 Screening DNA Stool Test for
Colorectal Cancer
08/25/2008 6145
Rev # Issue Date Subject Impl Date CR#
R92BP 06/27/2008 Private Contracting/Opting Out of
Medicare
09/29/2008 6081
R91BP 06/20/2008 Self-Administered Drug Exclusion
Lists
07/21/2008 5988
R88BP 05/07/2008 Therapy Personnel Qualifications
and Policies Effective January 1,
2008
06/09/2008 5921
R87BP 05/02/2008 Incident to Policy Update -
Rescinded
06/02/2008 5288
R86BP 04/18/2008 Payments for Medicare Part B
Services Furnished by Certain
Indian Health Service (IHS)
Hospitals and Clinics
05/19/2008 5807
R85BP 02/29/2008 Psychological and
Neuropsychological Tests
12/28/2006 5204
R84BP 02/29/2008 Update to Audiology Policies 04/07/2008 5717
R81BP 02/07/2008 Process for Amending the List of
Compendia for Determination of
Medically-Accepted Indications for
Off-Label Uses of Drugs and
Biologicals in an Anti-Cancer
Chemotherapeutic Regimen
03/07/2008 5870
R80BP 01/11/2008 Requirements for Ordering and
Following Orders for Diagnostic
Tests – Replaced by Transmittal 80
11/19/2007 5743
R79BP 10/19/2007 Requirements for Ordering and
Following Orders for Diagnostic
Tests – Replaced by Transmittal 80
11/19/2007 5743
R78BP 09/21/2007 Unlabeled Use for Anti-Cancer
Drugs – Medical Literature Used to
Determine Medically Accepted
Indications for Drugs and
Biologicals Used in Anti-Cancer
Treatment
10/22/2007 5729
Rev # Issue Date Subject Impl Date CR#
R77BP 08/29/2007 Testing and Implementation of
2008 Ambulatory Surgical Center
(ASC) Payment System Changes
01/07/2008 5680
R76BP 07/20/2007 Testing and Implementation of
2008 Ambulatory Surgical Center
(ASC) Payment System Changes –
Replaced by Transmittal 77
01/07/2008 5680
R75BP 08/17/2007 Nurse Practitioner (NP) Services
and Clinical Nurse Specialist
(CNS) Services
11/19/2007 5639
R74BP 06/29/2007 Medicare Telehealth Services 01/07/2008 5628
R72BP 05/25/2007 Guidelines for Payment of Diabetes
Self-Management Training
(DSMT)
07/02/2007 5433
R71BP 05/25/2007 Clarification of Manual Instruction
Regarding the Scope of Portable X-
Ray Benefit
07/02/2007 5536
R70BP 05/11/2007 Bone Mass Measurements (BMMs) 07/02/2007 5521
R64BP 01/19/2007 Guidelines for Payment of Diabetes
Self-Management Training
(DSMT) – Replaced by Transmittal
72
07/02/2007 5433
R63BP 12/29/2006 Outpatient Therapy Cap Exceptions
Process for Calendar Year (CY)
2007
01/29/2007 5478
R62BP 12/22/2006 Private Contracting-Definition of
Physician/Practitioner
04/02/2007 5426
R60BP 11/09/2006 Outpatient Therapy Cap
Clarification
01/02/2007 5271
R55BP 09/29/2006 Psychological and
Neuropsychological Tests –
Rescinded and Replaced by
Transmittal 85
12/28/2006 5204
Rev # Issue Date Subject Impl Date CR#
R53BP 07/07/2006 Medicare Telehealth Services
Update
08/07/2006 5122
R52BP 06/30/2006 Therapy Caps Exception Process 03/13/2006 4364
R51BP 06/23/2006 Requirements for Diagnostic X-
Ray, Diagnostic Laboratory, and
Other Diagnostic Tests; Clinical
Psychologist Services
09/21/2006 4400
R48BP 03/24/2006 Expansion of Glaucoma Screening
Services
04/03/2006 4365
R47BP 02/15/2006 Therapy Caps Exception Process 03/13/2006 4364
R46BP 02/13/2006 Therapy Caps Exception Process -
Rescinded and replaced by
Transmittal 47
03/13/2006 4364
R43BP 12/23/2005 List of Medicare Telehealth
Services
04/03/2006 4204
R37BP 08/12/2005 Conforming Changes for Change
Request 3648 to Pub. 100-02
09/12/2005 3912
R36BP 06/24/2005 Pub. 100-02, Chapter 15, Sections
220 and 230 Therapy Services
06/06/2005 3648
R34BP 05/06/2005 Pub. 100-02, Chapter 15, Sections
220 and 230 Therapy Services
06/06/2005 3648
R31BP 04/01/2005 List of Medicare Telehealth
Services
05/02/2005 3747
R30BP 02/18/2005 Policy for Repair and Replacement
of Durable Medical Equipment
(DME)
N/A 3693
R24BP 10/29/2004 Revision of Section 300.5.1,
Chapter 15 of the Medicare Benefit
Policy Manual to include 22x TOB
as an applicable TOB for Diabetes
Self-Management Training
01/03/2005 3531
R23BP 10/08/2004 Revised Requirements for
Chiropractic Billing of
10/04/2004 3449
Rev # Issue Date Subject Impl Date CR#
Active/Corrective Treatment and
Maintenance Therapy. Full
Replacement of CR 3063
R20BP 09/17/2004 Providing Information for Incident
to Services. Full Replacement of
CR CR 3242. - Rescinded
04/01/2005 3460
R18BP 09/03/2004 Revised Requirements for
Chiropractic Billing of
Active/Corrective Treatment and
Maintenance Therapy. Full
Replacement of CR 3063
10/04/2004 3449
R17BP 06/18/2004 Providing Information for Incident
to Services. - Replaced by
Transmittal 20-CR 3460.
10/04/2004 3242
R13BP 05/28/2004 Diabetes Self Management
Training Services
06/28/2004 3185
R12BP 05/28/2004 Chiropractor’s Services 10/04/2004 3063
R09BP 04/23/2004 Arrangements for Physical,
Occupational, and Speech
Language Pathology Services (PT,
OT, SLP)
05/24/2004 3134
R06BP 01/23/2004 Intravenous Immune Globulin 04/05/2004 3059
R05BP 01/09/2004 Coverage of Outpatient Physical
Therapy, Occupational Therapy and
Speech-Language Pathology
Services Under Medical Insurance
03/15/2004 2859 &
2779
R04BP 01/02/2004 Dentists, podiatrists, and
optometrists are added to the
definition/list of physicians who
may opt out of Medicare
02/02/2004 3016
R03BP 12/19/2003 Coverage of iFOBT 01/05/2004 2996
R01BP 10/01/2003 Introduction to the Benefit Policy
Manual
N/A N/A
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