(Medicare Claims Processing Manual)

This section sets forth special conditions that govern payments for services that physicians furnish in, or to patients of, providers of services including hospitals, SNFs, or Comprehensive Outpatient Rehabilitation Facilities ( CORFs).  If physicians are compensated for their services by a provider or another entity, the compensation they receive must be allocated among the various types of services they furnish.  The A/B MAC (A) pays for services that physicians furnish to the provider.  Physician services to the provider include, but are not limited to, standby surgical services.  Payment for physicians services to individual patients that meet the conditions in subsection A is made under the physicians fee schedule.  However:   Payment for physicians services furnished in teaching settings is subject to the additional conditions in 100;   Payment for physicians services furnished to ESRD patients is subject to additional requirements in Chapter 8, and  The A/B MAC (A) pays for the services of residents, as well as for physicians who are licensed to practice only in the provider setting, as provider services.  (See 100.2)   A. Conditions for Physician Fee Schedule Payment for Physicians Services to Patients in Providers   1. General  A/B MACs (B) pay for physicians services to patients of providers on a fee schedule basis only if the following requirements are met:   The services are personally furnished for an individual patient by a physician;   The services contribute directly to the diagnosis or treatment or an individual patient;   The services ordinarily require performance by a physician; and  In the case of anesthesiology, radiology, or pathology/laboratory services, certain additional requirements in 50, 60, and 70 are met.  2. Services of Physicians to Patients in Providers  If a physician furnishes services to a patient in a hospital or SNF that do not meet the requirements in 80.A.1, above, but are related to patient care, the services may be covered as provider services and paid by the A/B MAC (A) within the applicable Prospective Payment System (PPS) rate.  3. Effect of Billing Charges for Physician Services to Provider  If services furnished by a physician to a provider may be paid by the A/B MAC (A), neither the provider nor the physician may seek fee schedule payments from the A/B MAC (B), the beneficiary, or another insurer.  A/B MACs (B) must report any situation in w hich this happens to the RO unless it is clearly an isolated case of billing error.  4. Effect of Assumption of Operating Costs  If a physician or an entity enters into an agreement (such as a lease or concession) with a provider under which the physician (or entity) assumes some or all of the operating costs of the provider department:   A/B MACs (B) make fee schedule payments only for physicians services to individual patients;  The physician (or other entity) must make its books and records available to the provider and the A/B MAC (A), as necessary, to verify the nature and extent of the costs of the services furnished by the physician (or other entity); and   The lessees costs associated with producing these services, including overhead, supplies, equipment, and the costs of employing nonphysician personnel are payable by the A/B MAC (A) as provider services.  80.1 - Coverage of Physicians Services Provided in Comprehensive Outpatient Rehabilitation Facility  (Rev. 1, 10- 01-03) B3-2220  Rehabilitation services furnished by comprehensive outpatient rehabilitation facilities (CORFs) are covered by Medicare Part B.   Under 1832(a)(2)(E), and 1861(cc)(2) (go to http://www.ssa.gov/OP_Home/ssact/title18/1800.htm  and select the applicable title) and related provisions of the Act, a CORF is recognized as a provider of services on the basis of its reasonable costs.  Except for diagnostic and therapeutic services provided by physicians to individual patients, payment  is made to the CORF by A/B MACs (A) (acting in the role of the A/B MAC (B).)  Physicians diagnostic and therapeutic services furnished to a CORF patient are not considered CORF physicians services.  Instead they are services that the physician must bill to the A/B MAC (B).  If covered services, payment is made according to the Medicare Physician Fee Schedule.  When physicians diagnostic and therapeutic services are furnished in a CORF, the claim must be annotated to show the CORF as the place of treatment.  Services considered administrative services provided by the physician associated with the CORF are considered CORF services reimbursable to the CORF by the A/B MACs (A).  Administrative services include consultation with and medical supervision of nonphysi cian staff, establishing and reviewing the plan of treatment, and other medical and facility administration activities.  80.2 - Rural Health Clinic and Federally Qualified Health Center Services  (Rev. 1, 10- 01-03) B3-2260- 2260.3  Payment may be made under Part B for the medical and other health services furnished by a qualified rural health clinic (RHC) and Federally qualified health centers (FQHCs).  The covered services RHCs/FQHCs may offer are divided into two basic groups:  RHC /FQHC services (defined below) and other medical and other health services covered under Part B.  Items and services which meet the definition of RHC services or FQHC services are reimbursed either by designated RHC intermediaries, or a national FQHC FI in the case of independent RHCs/FQHCs, or by the providers A/B MAC (A) in the case of provider base d clinics.  In either case, the A/B MAC (B) does not pay claims for services defined as RHC/FQHC services.  The A/B MAC (A) pays for such services through a prospectively determined encounter rate.  Where an RHC or a FQHC is approved for billing other medical and health services to the A/B MAC (B), the RHC or FQHC bills the A/B MAC (B) and is paid according to the method of payment for the service provided. Rural health clinic and Federally qualified health center services are described in the Medicare Benefit Policy Manual, Chapter 13.  That chapter provides that the following services usually performed by physicians are included as services included in the encounter rate and therefore are not separately billable for RHC/FQHC patients.  They are:   Professional services performed by a physician for a patient including diagnosis, therapy, surgery, and consultation (See the Medicare Benefit Policy Manual, Chapter 15);   Services and supplies incident to a physicians services, as described in the Benefit Policy Manual, Chapter 15;   Nurse practitioner and physician assistant services (including the services of specialized nurse practitioners and nurse midwives) that would be covered if furnished by a physician, provided the nurse practitioner or physician assistant is legally permitte d to perform the services by the State in which they are performed;   Services and supplies incident to the services of nurse practitioners and physician assistants that would be covered if furnished incident to a physicians services, and   Visiting nurse  services to the homebound. However, the technical component of diagnostic services may be billed separately by the physician to the A/B MAC (B), if provided.  See Chapter 9, and the Medicare Benefit Policy Manual, Chapter 13, for additional information on the definition of RHC/FQHC services.  Also, an RHC or FQHC may provide other items and services which are covered under Part B, but which are not defined as RHC or FQHC services.  They are listed in the Medicare Benefit Policy Manual, Chapter 13.  Independent RHCs/FQHCs bill the A/B MAC (B) for such services.  Provider -based RHC/FQHC services are billed to the A/B MAC (A) as services of the parent provider.  Independent RHCs/FQHCs must enroll with the A/B MAC (B) in order to bill.  (See the Medicare Program Integrity Manual, Chapter 10, for enrollment instructions). 80.3 - Unusual Travel (CPT Code 99082)  (Rev. 1, 10- 01-03) B3-15026 In general, travel has been incorporated in the MPFSDB individual fees and is thus not separately payable.  A/B MACs (B) must pay separately for unusual travel (CPT code 99082) only when the physician submits documentation to demonstrate that the travel was very unusual. 90 - Physicians Practicing in Special Settings  (Rev. 1, 10- 01-03) 90.1 - Physicians in Federal Hospitals  (Rev. 1, 10- 01-03) B3-2020.5 There are many physicians performing services in hospitals operated by the Federal Government, e.g., military, Veterans Administration, and Public Health Service hospitals.  Normally Medicare does not pay for the services provided by a physician in a Feder al hospital except when the hospital provides services to the public generally as a community institution.  Such a physician working in the scope of his Federal employment may be considered as coming within the statutory definition of physician even though he may not have a license to practice in the State in which he is employed.  90.2 - Physician Billing for End -Stage Renal Disease Services  (Rev. 1, 10- 01-03) See the Medicare Benefit Policy Manual, Chapter 11, for a description of ESRD policy. See chapter 8, for billing requirements for physicians and facilities.  90.2.1 - Inpatient Hospital Visits With Dialysis Patients  (Rev. 1, 10 -01-03) B3-15062- 15062.1 Global billing practices that involve the submission of charges for each day that a patient is hospitalized are allowed.  Therefore, A/B MACs (B) may make payment for inpatient hospital visits that are specified relative to time, place, day, and services d irectly provided to inpatients.  This guideline may, however, differ with respect to daily visit charges for inpatient hospital visits with dialysis inpatients.  When an ESRD patient is hospitalized, the hospitalization may or may not be due to a renal -related condition.  In either case, the patient must continue to be dialyzed.  Chapter 8 provides policy and payment instructions for physicians services furnished to dialysis inpatients.  It also provides instructions for billing physicians renal -related medical services furnished on dialysis days and for dialysis and evaluation a nd management services performed on the same day.   90.3 - Physicians Services Performed in Ambulatory Surgical Centers (ASC)  (Rev. 1604, Issued: 09- 26-08, Effective: 01 -08-08, Implementation: 01- 05-09)  See Chapter 14, for a description of services that may be billed by an ASC and services separately billed by physicians.  The ASC payment does not include the professional services of the physician. These are billed separately by the physician. Physicians services include the services of anesthesiologists administering or supervising the administration of anesthesia to ASC patients and the patients recovery from the anesthesia. The term p hysicians services also includes any routine pre - or postoperative services, such as office visits, consultations, diagnostic tests, removal of stitches, changing of dressings, and other services which the individual physician usually performs.   The physician must enter the place of service code (POS) 24 on the claim to show that the procedure was performed in an ASC.   The A/B MAC (B) pays the facility fee from the MPFSDB to the physician. The facility fee is for services done in a facility other than the physicians office and is typically less than the nonfacility fee for services performed in the physicians office.   90.4 - Billing and Payment in a Health Professional Shortage Area (HPSA)  (Rev. 1273; Issued:  06- 29-07; Effective/Implementation Dates:  10 -01-07)  In accordance with 1833(m)  of the Act, physicians who provide covered professional services in any rural or urban HPSA are entitled to an incentive payment.  Beginning January 1, 1989, physicians providing services in certain classes of rural HPSAs were entitled to a 5- percent incentive payment.  Effective January 1, 1991, physicians providing services in either rural or urban HPSAs are eligible for a 10- percent incentive payment.   Eligibility for receiving the 10 percent bonus payment is based on whether the specific location at which the service is furnished is within an area that is designated (under section 332(a)(1)(A) of the Public Health Services Act) as a HPSA. The Health Res ources and Services Administration (HRSA), within the Department of Health & Human Services, is responsible for designating shortage areas.   HRSA designates three types of HPSAs:  geographic, population, and facility- based.  Geographic -based HPSAs are areas with shortages of primary care physicians, dentists or psychiatrists.  Population -based HPSAs are designations based on underserved populat ions within an area.  Facility -based HPSAs are designations based on a public or non- profit private facility that is providing services to an underserved area or population and has an insufficient capacity to meet their needs.