(Medicare Benefit Policy Manual)

of the Act . Such services can be covered only under the hospital or SNF benefit and payment for such services can be made to only the hospital or SNF by a A/B MAC (A) .  (See 80 concerning physician supervision of technicians performing diagnostic x- ray procedures in a physicians office.)   60.2 - Services of Nonphysician Personnel Furnished Incident To Physicians Services  (Rev. 1, 10-01-03) B3-2050.2  In addition to coverage being available for the services of such auxiliary personnel as nurses, technicians, and therapists when furnished incident to the professional services of a physician (as discussed in 60.1), a physician may also have the services of certain nonphysician practitioners covered as services incident to a physicians professional services.  These nonphysician practitioners, who are being licensed by the States under various programs to assist or act in the place of the physician, include, for example, certified nurse midwives, clinical psychologists, clinical social workers, physician assistants, nurse practitioners, and clinical nurse specialists.  (See 150 through 200 for coverage instructions for various allied health/nonphysician practitioners services.)  Services performed by these nonphysician practitioners incident to a physicians professional services include not only services ordinarily rendered by a physicians office staff person (e.g., medical services such as taking blood pressures and temperatures, giving injections, and changing dressings) but also services ordinarily performed by the physician such as minor surgery, setting casts or simple fractures, reading x-rays, and other activities that involve evaluation or treatment of a patients condition.  Nonetheless, in order for services of a nonphysician practitioner to be covered as incident to the services of a physician, the services must meet all of the requirements for coverage specified in 60 through 60.1.  For example, the services must be an integral, although incidental, part of the physicians personal professional services, and they must be performed under the physicians direct supervision.  A nonphysician practitioner such as a physician assistant or a nurse practitioner may be licensed under State law to perform a specific medical procedure and may be able (see 190 or 200, respectively) to perform the procedure without physician supervision and have the service separately covered and paid for by Medicare as a physician assistants or nurse practitioners service.  However, in order to have that same service covered as inci dent to the services of a physician, it must be performed under the direct supervision of the physician as an integral part of the physicians personal in-office service.  As explained in 60.1, this does not mean that each occasion of an incidental service performed by a nonphysician practitioner must always be the occasion of a service actually rendered by the physician.  It does mean that there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the nonphysician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physicians continuing active participation in and management of the course of treatment.  In addition, the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary.   Note also that a physician might render a physicians service that can be covered even though another service furnished by a nonphysician practitioner as incident to the physicians service might not be covered.  For example, an office visit during which the physician diagnoses a medical problem and establishes a course of treatment could be covered even if, during the same visit, a nonphysician practitioner performs a noncovered service such as acupuncture.  60.3 - Incident To Physicians Services in Clinic  (Rev. 1, 10-01-03) B3-2050.3  Services and supplies incident to a physicians service in a physician directed clinic or group association are generally the same as those described above.   A physician directed clinic is one where:   1.  A physician (or a number of physicians) is present to perform medical (rather than administrative) services at all times the clinic is open;  2.  Each patient is under the care of a clinic physician; and  3.  The nonphysician services are under medical supervision.  In highly organized clinics, particularly those that are departmentalized, direct physician supervision may be the responsibility of several physicians as opposed to an individual attending physician.  In this situation, medical management of all services provided in the clinic is assured.  The physician ordering a particular service need not be the physician who is supervising the service.  Therefore, services performed by auxiliary personnel and other aides are covered even though they are performed in another department of the clinic.  Supplies provided by the clinic during the course of treatment are also covered.  When the auxiliary personnel perform services outside the clinic premises, the services are covered only if performed under the direct supervision of a clinic physician.  If the clinic refers a patient for auxiliary services performed by personnel who are not supervised by clinic physicians, such services are not incident to a physicians service.   60.4 - Services Incident to a Physicians Service to Homebound Patients Under General Physician Supervision  (Rev. 1, 10-01-03) B3-2051  A.  When Covered   In some medically underserved areas there are only a few physicians available to provide services over broad geographic areas or to a large patient population.  The lack of medical personnel (and, in many instances, a home health agency servicing the area)  significantly reduces the availability of certain medical services to homebound patients.  Some physicians and physician-directed clinics, therefore, call upon nurses and other paramedical personnel to provide these services under general (rather than direct) supervision.  In some areas, such practice has tended to become the accepted method of delivery of these services.   The Senate Finance Committee Report accompanying the 1972 Amendments to the Act recommended that the direct supervision requirement of the incident to provision be modified to provide coverage for services provided in this manner.  Accordingly, to permit coverage of certain of these services, the direct supervision criterion in 60.2 above is not  applicable to individual or intermittent services outlined in this section when they are performed by personnel meeting any pertinent State requirements (e.g., a nurse, technician, or physician extender) and where the criteria listed below also are met:   1 The patient is homebound; i.e., confined to his or her home (see 60.4.1  for the definition of a homebound patient and 110.1 (D)  for the definition of patients place of residence.  2 The service is an integral part of the physicians service to the patient (the patient must be one the physician is treating), and is performed under general physician supervision by employees of the physician or clinic.  General supervision means that the physician need not be physically present at the patients place of residence when the service is performed; however, the service must be performed under his or her overall supervision and control.  The physician orders the service(s) to be performed, and contact is maintained between the nurse or other employee and the physician, e.g., the employee contacts the physician directly if additional instructions are needed, and the physician must retain professional responsibility for the service.  All other incident to requirements must be met (see 60-60.4).  3 The services are included in the physicians/clinics bill, and the physician or clinic has incurred an expense for them (see 60.2 ).  4 The services of the paramedical are required for the patients care; that is, they are reasonable and necessary as defined in the Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage, 20.  5 When the service can be furnished by an HHA in the local area, it cannot be covered when furnished by a physician/clinic to a homebound patient under this provision, except as described in 60.4.C.  B.  Covered Services   Where the requirements in 60.4.A are met, the direct supervision requirement in 60.2 is not applicable to the following services:  1. Injections;  2. Venipuncture;  3. EKGs;   4. Therapeutic exercises;   5. Insertion and sterile irrigation of a catheter;   6. Changing of catheters and collection of catheterized specimen for urinalysis and culture;   7. Dressing changes, e.g., the most common chronic conditions that may need dressing changes are decubitus care and gangrene;   8. Replacement and/or insertion of nasogastric tubes;   9. Removal of fecal impaction, including enemas;   10. Sputum collection for gram stain and culture, and possible acid- fast and/or fungal stain and culture;   11. Paraffin bath therapy for hands and/or feet in rheumatoid arthritis or osteoarthritis;   12. Teaching and training the patient for:   a. The care of colostomy and ileostomy;   b. The care of permanent tracheostomy;   c. Testing urine and care of the feet (diabetic patients only); and  d. Blood pressure monitoring.  Teaching and training services (also referred to as educational services) can be covered only where they provide knowledge essential for the chronically ill patients participation in his or her own treatment and only where they can be reasonably related to such treatment or diagnosis.  Educational services that provide more elaborate instruction than is necessary to achieve the required level of patient education are not covered.  After essential  information has been provided, the patient should be relied upon to obtain additional information on his or her own.   C.  Relation to Home Health Benefits   This coverage should not be considered as an alternative to home health benefits where there is a participating home health agency in the area which could provide the needed services on a timely basis.  For example, two of the three services initially included under this coverage -  injections and venipuncture -  are skilled nursing services that could be covered as home health services (EKG is not a covered Home Health Agency (HHA) service) if the patient is eligible for home health benefits and there is a h ome health agency available.  Thus, postpayment review of these claims will include measures to assure that physicians and clinics do not provide a substantial number of services under this coverage when they could otherwise have been performed by a home health agency.   In these circumstances, the physician or clinic is expected to assist the patient in obtaining such skilled services together with the other home health services (such as aide services).  However, HHA services are not considered available where the HHA can not respond on a timely basis or where the physician could not have foreseen that intermittent services would be needed.   Refer to the Medicare Claims Processing Manual, Chapter 10, Home Health Agency Billing, for a more in depth discussion of home health services.  60.4.1 - Definition of Homebound Patient Under the Medicare Home Health (HH) Benefit  (Rev. 192, Issued: 08- 01-14, Effective: 09 -02-14, Implementation: 09- 02-14)  This definition applies to homebound for purposes of the Medicare home health benefit.   For a patient to be eligible to receive covered home health services, the law requires that a physician certify in all cases that the patient is confined to his/her home.  For purposes of the statute, an individual shall be considered confined to the home  (homebound) if the following two criteria are met:   1. Criteria -One:   The patient must either:   - Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence   OR  - Have a condition such that leaving his or her home is medically contraindicated.   If the patient meets one of the Criteria -One conditions, then the patient must ALSO meet two additional requirements defined in Criteria -Two below.   2. Criteria -Two:   - There must exist a normal inability to leave home;  AND   - Leaving home must require a considerable and taxing effort.   If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment.  Ab sences attributable to the need to receive health care treatment include, but are not limited to:    Attendance at adult day centers to receive medical care;    Ongoing receipt of outpatient kidney dialysis; or    The receipt of outpatient chemotherapy or radiation therapy.