(Medicare Benefit Policy Manual)

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 masters or doctors 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 masters degree supervised clinical social work practice under the supervision of a masters level social wo rker 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 physicians 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 physicians 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 CSWs 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 service s 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 -midwifes 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 midwifes 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 patients 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 member s 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 mothers 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 att ention.  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-midwifes 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 -midwifes office, in the patients home, or in a hospital or other facility, such as a clinic or birthing center owned or operated by a nur se-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 Progr ams (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 physicians 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 PAs 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 patients 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 assistants 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.