(Medicare Benefit Policy Manual)

110.8  DMEPOS Benefit Category Determination s 120 -  Prosthetic Devices  130 -  Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes  140 -  Therapeutic Shoes for Individuals with Diabetes  150 -  Dental Services  150.1 -  Treatment of Temporomandibular Joint (TMJ) Syndrome  160 -  Clinical Psychologist Services  170 -  Clinical Social Worker (CSW) Services  180 -  Nurse -Midwife (CNM) Services  190 -  Physician Assistant (PA) Services  200 -  Nurse Practitioner (NP) Services  210 -  Clinical Nurse Specialist (CNS) Services  220 -  Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech -Language Pathology Services) Under Medical Insurance  220.1 -  Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech -Language Pathology Services  220.1.1 -  Care of a Physician/Nonphysician Practitioner (NPP)  220.1.2 -  Plans of Care for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services  220.1.3 -  Certification and Recertification of Need for Treatment and Therapy Plans of Care  220.1.4 -  Requirement That Services Be Furnished on an Outpatient Basis  220.2 -  Reasonable and Necessary Outpatient Rehabilitation Therapy Services  220.3 -  Documentation Requirements for Therapy Services  220.4 -  Functional Reporting 230 -  Practice of Physical Therapy, Occupational Therapy, and Speech -Language Pathology 230.1 -  Practice of Physical Therapy  230.2 -  Practice of Occupational Therapy  230.3 -  Practice of Speech -Language Pathology 230.4 -  Services Furnished by a Therapist in Private Practice (TPP)  230.5 -  Physical Therapy, Occupational Therapy and Speech- Language Pathology Services Provided Incident to the Services of Physicians and Nonphysician Practitioners  (NPP)  230.6 -  Therapy Services Furnished Under Arrangements With Providers and Clinics  231 -  Pulmonary Rehabilitation (PR) Program Services Furnished on or After January 1, 2010  232 -  Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Services Furnished On or After January 1, 2010  240 -  Chiropractic Services -  General  240.1 -  Coverage of Chiropractic Services  240.1.1 -  Manual Manipulation 240.1.2 -  Subluxation May Be Demonstrated by X -Ray or Physicians Exam  240.1.3 -  Necessity for Treatment  240.1.4  Location of Subluxation 240.1.5 -  Treatment Parameters  250 -  Medical and Other Health Services Furnished to Inpatients of Hospitals and Skilled Nursing Facilities  260 -  Ambulatory Surgical Center Services  260.1 -  Definition of Ambulatory Surgical Center (ASC)  260.2 -  Ambulatory Surgical Center Services  260.3 -  Services Furnished in ASCs Which are Not ASC Facility Services  260.4 -  Coverage of Services in ASCs, Which are Not ASC Services  260.5 -  List of Covered Ambulatory Surgical Center Procedures  260.5.1 -  Nature and Applicability of ASC List  260.5.2 -  Nomenclature and Organization of the List  260.5.3 -  Rebundling of CPT Codes  270 -  Telehealth Services  280  Preventive and Screening Services  280.1  Glaucoma Screening  280.2 -  Colorectal Cancer Screening  280.2.1 -  Covered Services and HCPCS Codes  280.2.2 -  Coverage Criteria 280.2.3 -  Determining Whether or Not the Beneficiary is at High Risk for Developing Colorectal Cancer  280.2.4 -  Determining Frequency Standards  280.2.5 -  Noncovered Services  280.3 -  Screening Mammography  280.4 -  Screening Pap Smears  280.5 -  Annual Wellness Visit (AWV) Providing Personalized Prevention Plan Services (PPPS)  280.5.1  Advance Care Planning (ACP) Furnished as an Optional Element with an Annual Wellness Visit (AWV) upon Agreement with the Patient 290 -  Foot Care  300 -  Diabetes Self -Management Training Services  300.1 -  Beneficiaries Eligible for Coverage and Definition of Diabetes  300.2 -  Certified Providers  300.3 -  Frequency of Training 300.4 -  Coverage Requirements for Individual Training 300.4.1-  Incident - To Provision 300.5 -  Payment for DSMT  300.5.1 -  Special Claims Processing Instructions  A/B MACs (A)  310  Kidney Disease Patient Education Services  310.1 -  Beneficiaries Eligible for Coverage  310.2 -  Qualified Person  310.3 -  Limitations for Coverage  310.4 -  Standards for Content  310.5 -  Outcomes Assessment  320  Home Infusion Therapy Services  320.1  General Requirements for Payment of Home Infusion Therapy Services  320.2  Home Infusion Therapy Services Benefit is Separate from DME Benefit  320.3  Qualified Home Infusion Therapy Suppliers   320.4  Patient Eligibility for Home Infusion Therapy    320.4.1 -  Home Infusion Therapy Services for Homebound Patients  320.5  Plan of Care Requirements   320.5.1 -  Notification of Available Infusion Therapy Options  320.5.2 -  Plan of Care Periodic Review and Provider Coordination 320.6  Professional Services, Including Nursing Services, for Home Infusion               Therapy  320.6.1 -  Home Infusion Therapy Services Training and Education  320.6.2 -  Remote Monitoring and Monitoring Services  320.7  Home Infusion Therapy Drugs  320.7.1 -  Determining Qualifying Home Infusion Drugs  320.8  Determining Qualifying Home Infusion Drugs   320.8.1 -  Home Infusion Drug Payment Categories  320.8.2 -  Infusion Drug Administration Calendar Day and Unit of Single Payment  320.8.3 -  Initial Visits and Subsequent Visits for Home Infusion Therapy Services  320.9 Medical Review    330- Marriage and Family Therapist (MFT) Services    340-  Mental  Health Counselor (MHC) Services   10 - Supplementary Medical Insurance (SMI) Provisions  (Rev. 11355; Issued:04- 14-22; Effective: 05 -16-22; Implementation: 05 -16-22)  The supplementary medical insurance plan covers expenses incurred for the following medical and other health services under Part B of Medicare:    Physicians services, including surgery, consultation, office and institutional calls, and services and supplies furnished incident to a physicians professional service;    Outpatient hospital services furnished incident to physicians services;    Outpatient diagnostic services furnished by a hospital;    Outpatient physical therapy, outpatient occupational therapy, outpatient speech- language pathology services;    Diagnostic x- ray tests, laboratory tests, and other diagnostic tests;    X-ray, radium, and radioactive isotope therapy;    Surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations;    Rental or purchase of durable medical equipment for use in the patients home;    Ambulance service;    Prosthetic devices, other than dental, which replace all or part of an internal body organ;    Leg, arm, back and neck braces and artificial legs, arms, and eyes including adjustments, repairs, and replacements required because of breakage, wear, loss, or change in the patients physical condition;    Certain medical supplies used in connection with home dialysis delivery systems;    Rural health clinic (RHC) services;    Federally Qualified Health Center (FQHC) services;    Ambulatory surgical center (ASC) services;    Screening mammography services;    Screening pap smears and pelvic exams;    Screening glaucoma services;    Influenza, pneumococcal pneumonia, hepatitis B, and COVID -19 vaccines;    Colorectal screening;    Bone mass measurements;    Diabetes self -management services;    Prostate screening; and    Home health visits after all covered Part A visits have been used.  See 250  for provisions regarding supplementary medical insurance coverage of certain of these services when furnished to hospital and SNF inpatients.  Payment may not be made under Part B for services furnished an individual if the individual is entitled to have payment made for those services under Part A.  An individual is considered entitled to have payment made under Part A if the expenses incurred were used to satisfy a Part A deductible or coinsurance amount, or if payment would be made under Part A except for the lack of a request for payment or lack of a physician certification.   Some medical services may be considered for coverage under more than one of the above- enumerated categories.  For example, electrocardiograms (EKGs) can be covered as physicians services or as other diagnostic tests.  It is sufficient to determine that th e requirements for coverage under one category are met to permit payment.   Membership dues, subscription fees, charges for service policies, insurance premiums, and other payments analogous to premiums which entitle enrollees to services or to repairs or replacement of devices or equipment or parts thereof without charge or at a reduced charge, are not considered expenses incurred for covered items or services furnished under such contracts or undertakings.  Examples of such arrangements are memberships in ambulance companies, insurance for replacement of prosthetic lenses, and se rvice contracts for durable medical equipment.  20 - When Part B Expenses Are Incurred  (Rev. 1, 10-01-03) B3-2005  Part B expenses for items and services other than expenses for surgery and childbirth (see 20.1, below), are considered to have been incurred on the date the beneficiary received the item or service, regardless of when it was paid for or ordered.  Therefore, when an individual orders an item prior to his or her entitlement to supplemental medical insurance (SMI) but receives the item after the effective date of SMI enrollment, the expense is considered incurred after entitlement began.  However, if an item not  custom-made for the beneficiary was ordered but not furnished, no reimbursement can be made.  (See 20.3 for rules concerning custom-made items ordered but not furnished and the Medicare Claims Processing Manual, Chapter 20, Durable Medical Equipment, Prosthetics and Orthotics, and Supplies (DMEPOS), for additional rules concerning the date of incurred expenses for durable medical equipment.)  20.1 - Physician Expense for Surgery, Childbirth, and Treatment for Infertility  (Rev. 1, 10-01-03) B3-2005.l  A.  Surgery and Childbirth  Skilled medical management is covered throughout the events of pregnancy, beginning with diagnosis, continuing through delivery and ending after the necessary postnatal care.  Similarly, in the event of termination of pregnancy, regardless of whether terminated 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 important as in those cases carried to ful l term.  After the infant is delivered and is a separate individual, items and services furnished to the infant are not covered on the basis of the mothers eligibility.  Most surgeons and obstetricians bill patients an all- inclusive package charge intended to cover all services associated with the surgical procedure or delivery of the child.  All expenses for surgical and obstetrical care, including preoperative/prenatal examinations and tests and post- operative/postnatal services, are considered incurred on the date of surgery or delivery, as appropriate.  This policy applies whether the physician bills on a package charge basis, or i temizes the bill separately for these items.   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