(Medicare Benefit Policy Manual)

Occasionally, a physicians 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 -operativ e/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 f ertile 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 beneficiarys condition changed and the item was no longer reasonable and necessary or appropriate, payment can be made based on the suppliers 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 beneficiarys condition.  If the beneficiary died or the beneficiarys 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 beneficiarys death or of the cancellation of the order or that the item was no longer reasonable and necessary or appropriate.  The A/B MA C (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 ite m.  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 physicians service  where the physician either examines the patient in person or is able to visualize some aspect of the patients condition without the interposition of a third persons 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 patients home, for this purpose, is anywhere the patient makes his or her resi dence, e.g., home for the aged, a nursing home, a relatives 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 consulta tion 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, i f 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 patients need for a procedure and to render a professional opinion.  I n 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 patients 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 patients 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 patients 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 patients condition and the inherent reasonableness and necessity of the services, as determ ined 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 patients condition, payment may be made only for the other physicians (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 s pecial 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 patients condition necessitates treatment by both physicians.  The leve l of difficulty of the service provided may vary between the physicians, depending on the severity of the complaint each one is treating and that physicians 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 conditi on.  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 patients 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 patients 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 patients 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 physicians nurse or the time spent consulting with ones 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;