(Medicare Benefit Policy Manual)

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;   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 physicians 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 patients 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 patients 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 practitioners 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 pr oviders 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 physicians 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 physicians services pertains to that part of the physicians activities that is directly related to the medical care of the individual patient.  It represents remuneration for the identifiable medical service s by the physician that contribute to the diagnosis of the patients 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 s chedule.   B.  The Provider Component   The portion of the physicians 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 providers 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 physicians 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 patients 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 patients progress.  The medical record must contain signed or countersigned notes by the physician which show that the physician personally reviewed the patients diagnoses, visited the patient at more critical times of the illness, and discharged the patient.  For other se rvices, 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 teach ing 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., indi viduals 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 residents 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 servi ces 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 patients 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 - Optometrists 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 neces sary 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 practitioners services were reasonable and necessary.  (See 30.E.)  30.5 - Chiropractors Services  (Rev. 23, Issued: 10-08- 04, Effective: 10 -01-04, Implementation: 10-04-04) B3-2020.26