(Medicare Benefit Policy Manual)

 Is eligible for a certification of clinical competence in audiology granted by the American Speech and Hearing Association; or   Meets the education requirements for certification and is in the process of accumulating the supervised experience required for certification.   50.1 - Therapeutic Items  (Rev. 1, 10-01-03) A3-3101.5.A, HO-210.5  Therapeutic items, which are covered when ordinarily furnished by the hospital to its inpatients, or when ordinarily furnished to hospital inpatients by others under arrangements with them made by the hospital, include but are not limited to  the following:   Surgical dressings, and splints, casts, and other devices used for the reduction of fractures and dislocations;   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; and    Leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes.  With respect to items that leave the hospital with the patient upon discharge, such as splints or casts, the rules for determining whether the item is covered are the same as the rules set forth above for supplies, appliances, and equipment.  50.2 - Diagnostic Services of Psychologists and Physical Therapists  (Rev. 1, 10-01-03) A3-3101.5.B, HO-210.5  When a psychologist or physical therapist is a salaried member of the staff of a hospital, their diagnostic or therapeutic services to inpatients of that hospital are covered.  See the Medicare Claims Processing Manual for info rmation on distinguishing between professional and technical services, and for information about billing and payment for nonphysician practitioners.  50.3 - Diagnostic Services Furnished to an Inpatient by an Independent Clinical Laboratory Under Arrangements With the Hospital  (Rev. 1, 10-01-03) A3-3101.5.C, HO-210.5  Diagnostic services furnished to an inpatient by an independent clinical laboratory under arrangements with the hospital are reimbursable under hospital insurance provided the lab is certified  by CLIA to perform the services.   An independent laboratory is one which is independent both of an attending  or consulting physician's office and also independent of any hospital which meets at least the requirements to qualify as an emergency hospital (e.g., maintains clinical records, has a utilization review plan, meets the health and safety requirements found necessary by the Secretary of Health and Human Services).   A consulting physician is one whose services include history taking, examination of the patient and, in each case, furnishing to the attending physician an opinion regarding diagnosis or treatment.  A physician providing clinical laboratory services for patients of other physicians is not considered to be a consulting physician.   A labora tory operated by or under the supervision of a hospital (or the organized medical staff of the hospital) that does not meet at least the definition of an emergency hospital is considered to be an independent laboratory.  However, a laboratory serving hospi tal patients and operated on the premises of a hospital that meets the definition of an emergency hospital is presumed to be subject to the supervision of the hospital or its organized medical staff and is not an independent laboratory.  A laboratory that a physician or group of physicians maintains for performing diagnostic tests in connection with their own or the group practice is also not considered to be an independent laboratory.   An out -of-hospital laboratory is ordinarily presumed to be independent unless there is written evidence establishing that it is operated by or under the supervision of a hospital that meets at least the definition of an emergency hospital or of the organized medical staff of such a hospital.  Refer to The Conditions of Parti cipation for Hospitals found at 42 CFR 482 and below for a description of independent lab approval requirements when the hospital is participating.   Where a laboratory operated on hospital premises is claimed to be independent or where an out -of-hospital facility is designated as a hospital laboratory, the CMS regional office makes the determination concerning the laboratory's status.   A clinical labor atory is a laboratory where microbiological, serological, chemical, hematological, radiobioassay, cytological, immunohematological, or pathological examinations are performed on materials derived from the human body, to provide information for the diagnosi s, prevention, or treatment of a disease or assessment of a medical condition.  The "Conditions of Participation for Hospitals (HIRM -1)" call for independent clinical laboratory services furnished under arrangements made by a hospital to be furnished only by a laboratory meeting the specified conditions for coverage under the program.  These require that:    Where State or applicable local law provides for licensing of independent clinical laboratories, the laboratory is either licensed under law or is approv ed as meeting the requirements for licensing by the State or local agency responsible for licensing laboratories; and    Such laboratories also meet the health and safety requirements prescribed by the Secretary of Health and Human Services.  (See The Cond itions of Participation for Hospitals at 42 CFR 482).  Where independent laboratory services are provided to patients of a participating hospital unde r arrangements with the hospital, the law does not require as a condition of payment in an individual case that the independent laboratory be approved under the program.  In processing individual claims, the A/B MAC (A), therefore, need not verify that the services were obtained from an approved laboratory.  The A/B MAC (A) should make payment for laboratory services although it may know that the laboratory from which the hospital has obtained the service is not approved under the program.  However, it should promptly refer this information to the appropriate regional office for review of the determination of the hospital's compliance with the conditions of participation and for whatever action the regional office deems appropriate.  The above policy applies  to PPS exempt hospitals. Note that under PPS, there is no separate payment for lab services furnished to inpatients.  50.4 - Diagnostic Services Furnished a Hospital Inpatient Under Arrangement With the Laboratory of Another Participating Hospital  (Rev. 1, 10-01-03) A3-3101.5.D, HO-210.5  Diagnostic services furnished a hospital inpatient under arrangements with the laboratory of another participating hospital are reimbursable on a cost basis under Part A to the hospital obtaining the services if the hospital is PPS exempt.  If the hospital is not exempt, there is not separate payment for lab services furnished to inpatients.  NOTE :  Where a PPS exempt hospital obtains diagnostic laboratory services for inpatients under arrangements described in 50.3 and 50.4 the cost to the hospital obtaining the services would be the reasonable charge for the laboratory's service.  60 - Services of Interns or Residents -In-Training  (Rev. 1, 10-01-03) A3-3101.6, HO-210.6  Hospital insurance covers the reasonable cost of the services of medical or osteopathic interns or residents- in-training under a teaching program approved by the appropriate approving body.  In the case of services of interns or residents- in-training in the field of dentistry in a hospital or osteopathic hospital, the teaching program must have the approval of the Council on Dental Education of the American Dental Association.  The services of interns and residents- in-training in the field of podiatry who are in a residency program approved by the Council on Podiatric Medical Education of the American Podiatric Medical Association are covered on the same basis as the services of other interns and residents in other approved resi dency programs.   70 - Inpatient Services in Connection With Dental Services  (Rev. 1, 10-01-03) A3-3101.7, HO-210.7  When a patient is hospitalized for a dental procedure and the dentist's service is covered under Part B, the inpatient hospital services furnished are covered under Part A.  For example, both the professional services of the dentist and the inpatient hospital expenses are covered when the dentist reduces a jaw fracture of an inpatient at a participating hospital.  In addition, hospital inpatie nt services, which are necessary because of the patient's underlying medical condition and clinical status or the severity of a noncovered dental procedure, are covered.   When the hospital services are covered, all ancillary services such as x -rays, administration of anesthesia, use of the operating room, etc., are covered.  Regardless of whether the inpatient hospital services are covered, the medical services of physicians furnished in connection with noncovered dental services are not covered.  The servi ces of an anesthesiologist, radiologist, or pathologist whose services are performed in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth are not covered.  80 - Health Care Associated Wit h Pregnancy  (Rev. 1, 10-01-03) A3-3101.12, HO-210.13  Reasonable and necessary services associated with pregnancy are covered and reimbursable under the Medicare program.  Because pregnancy is a condition sufficiently at variance with the usual state of health, it is appropriate for a pregnant woman to seek medical care.  The increased possibility of illness or injury accompanying this condition is well recognized, and medical supervision is required throughout pregnancy and for a brief period beyond.  Skilled medical management is appropriate throughout the events of pregnancy, beginning with diagnosis of the condition, continuing through delivery, and ending after the necessary postnatal care.  Similarly, if the pregnancy terminates, whether 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 as important as in those cases carried to full term.  After the infant is delivered, items and services furnished to the infant cannot be covered and reimbursed under the program on the basis of the mother's eligibility.  90 - Termination of Pregnancy  (Rev. 1, 10-01-03) B3-4276.1,.2  Effective for services furnishe d on or after October 1, 1998, Medicare will cover abortions procedures in the following situations:  1.  If the pregnancy is the result of an act or rape or incest; or  2.  In the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life -endangering physical condition caused by the pregnancy itself that would, as certified by a physician, place the woman in danger of death unless an abortion is performed.  NOTE:   The "G7" modifier must be used with the following CPT codes in order for these services to be covered when the pregnancy resulted from rape or incest, or the pregnancy is certified by a physician as life threatening to the mother:   59840 59841 59850 59851 59852 59855 59856 59857 59866  100 - Treatment for Infertility (Rev. 1, 10-01-03) A3-3101.13  Effective for services rendered on or after January 15, 1980, reasonable and necessary services associated with treatment for infertility are covered under Medicare.  Like pregnancy (see 80 above), infertility is a condition sufficiently at variance with the usual state of health to make it appropriate for a person who normally would be expected to be fertile to seek medical consultation and treatment.  A/B MACs (A)  should coordinate with QIOs to see that utilization guidelines are established for this treatment if inappropriate utilization or abuse is suspected.  110 - Inpatient Rehabilitation Facility (IRF) Services  (Rev. 10892; Issued: 08-06- 21; Effective: 11 -08-21; Implementation: 11-08-21)   The inpatient rehabilitation facility (IRF) benefit is designed to provide intensive rehabilitation therapy in a resource intensive inpatient hospital environment for patients who, due to the complexity of their nursing, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary team approach  to the delivery of rehabilitation care.   The IRF benefit is not to be used as an alternative to completion of the full course of treatment in the referring hospital.  A patient who has not yet completed the full course of treatment in the referring hospital is expected to remain in the referring hospital, with appropriate rehabilitative treatment provided, until such time as the patient has completed the full course of treatment.  Though medical management can be performed in an IRF, patients must be  able to actively participate in and benefit from the intensive rehabilitation therapy program provided in IRFs in order  for an IRF claim to be considered reasonable and necessary, in accordance with 42 CFR   412.622(a)(3)(ii).  Therefore, patients who are not able to actively participate in and benefit from the intensive rehabilitation therapy services because they are still completing their course of treatment in the referring hospital should remain in the referring hospital until they are able to do so.   Conversely, the IRF benefit is not appropriate for patients who have completed their full course of treatment in the referring hospital, but do not require intensive rehabilitation. Medicare benefits are available for such patients in a less -intensive s etting.