(Medicare Benefit Policy Manual)

 American Academy of Nurse Practitioners;   American Nurses Credentialing Center;   National Certification Corporation for Obstetric, Gynecologic and Neonatal Nursing Specialties;  Pediatric Nursing Certification Board (previously named the National Certification Board of Pediatric Nurse Practitioners and Nurses);   Oncology Nurses Certification Corporation;   AACN Certification Corporation;   National Board on Certification of Hospice and Palliative Nurses; and,   Nurse Portfolio Credentialing Commission.   B.  Covered Services   Coverage is limited to the services a CNS is legally authorized to perform in accordance with State law (or State regulatory mechanism provided by State law).   1.  General   The services of a CNS may be covered under Part B if all of the following conditions are met:   They are the types of services that are considered as physicians services if furnished by an MD/DO;    They are furnished by a person who meets the CNS qualifications (see subsection A);    The CNS is legally authorized to furnish the services in the State in which they are performed;    They are furnished in collaboration with an MD/DO as required by State law (see subsection C); and   They are not otherwise excluded from coverage because of one of the statutory exclusions. (See subsection C.)   2.  Types of CNS Services that May be Covered   State law or regulations governing a CNS scope of practice in the State in which the services are furnished applies.  A/B MACs (B) must develop a list of covered services based on the State scope of practice.   Examples of the types of services that a CNS may furnish include services that traditionally have been reserved for physicians, such as physical examinations, minor surgery, setting casts for simple fractures, interpreting x- rays, and other activities that  involve an independent evaluation or treatment of the patients condition.  Also, if authorized under the scope of his or her State license, a CNS may furnish services billed under all levels of evaluation and management codes and diagnostic tests if furnished in collaboration with a physician.  3.  Incident To   If covered CNS services are furnished, services and supplies furnished incident to the services of the CNS may also be covered if they would have been covered when furnished incident to the services of an MD/DO as described in 60.  4. 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 Clinical Nurse Specialist (CNS) covered services, the CNS 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 stu dents or other members of the medical team, including as applicable, notes documenting the CNSs 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.  C.  Application of Coverage Rules  1.  Types of CNS Services  Examples of the types of services that CNS may provide are services that traditionally have been reserved for physicians, such as physical examinations, minor surgery, setting casts for simple fractures, interpreting x -rays, and other activities that invol ve an independent evaluation or treatment of the patients condition.  State law or regulation governing a CNS scope of practice for his or her service area applies.  2.  Services Otherwise Excluded From Coverage  A CNS services are not covered if they are otherwise excluded from coverage even though a CNS may be authorized by State law to perform them.  For example, the Medicare law excludes from coverage routine foot care and routine physical checkups and services that are not reasonable and necessary for diagnosis or treatment of an illness or injury or to improve the function of a malformed body member.  Therefore, these services are precluded from coverage even though they may be within a CNS scope of practice under State law.   See 60.2  for coverage of services performed by a CNS incident to the services of physicians.  D.  Collaboration  Collaboration is a process in which a CNS works with one or more physicians (MD/DO) to deliver health care services within the scope of the CNS professional expertise with medical direction and appropriate supervision as required by the law of the State in which the services are furnished.  In the absence of State law governing collaboration, collaboration is to be evidenced by the CNS documenting his or her scope of practice and indicating the relationships that the CNS has with physicians to deal with is sues outside the CNS scope of practice.   The collaborating physician does not need to be present with the CNS when the services are furnished or to make an independent evaluation of each patient who is seen by the CNS.   E.  Direct Billing and Payment  A CNS may bill directly and receive direct payment for their services.   F.  Assignment Requirement   Assignment is required for the service to be covered.  220 - Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech -Language Pathology Services) Under Medical Insurance  (Rev. 12425; Issued: 12-21- 23: Effective: 01 -01-24; Implementation: 01-02-24)      A comprehensive knowledge of the policies that apply to therapy services cannot be obtained through manuals alone.  The most definitive policies are Local Coverage Determinations found at the Medicare Coverage Database www.cms.hhs.gov/mcd.  A list of Medicare contractors is found at the CMS Web site.  Specific questions about all Medicare policies should be addressed to the contractors through the contact information supplied on their Web sites.  General Medicare questions may be addressed to the Medicare regional offices http://www.cms.hhs.gov/RegionalOffices/ .    A.  Definitions    The following defines terms used in this section and 230:    ACTIVE PARTICIPATION of the clinician in treatment means that the clinician personally furnishes in its entirety at least 1 billable service on at least 1 day of treatment.    ASSESSMENT is separate from evaluation, and is included in services or procedures, (it is not separately payable).  The term assessment as used in Medicare manuals related to therapy services is distinguished from language in Current Procedural Terminology (CPT) codes that specify assessment, e.g., 97755, Assistive Technology Assessment, which may be payable).  Assessments shall be provided only by clinicians, because assessment requires professional skill to gather data by observation and patient inquiry a nd may include limited objective testing and measurement to make clinical judgments regarding the patient's condition(s).  Assessment determines, e.g., changes in the patient's status since the last visit/treatment day and whether the planned procedure or service should be modified.  Based on these assessment data, the professional may make judgments about progress toward goals and/or determine that a more complete evaluation or re- evaluation (see definitions below) is indicated.  Routine weekly assessments  of expected progression in accordance with the plan are not payable as re- evaluations.    CERTIFICATION is the physicians/nonphysician practitioners (NPP) approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.    The CLINICIAN is a term used in this manual and in Pub 100- 04, chapter 5, section 10 or section 20, to refer to only a physician, nonphysician practitioner or a therapist (but not to an assistant, aide or any other personnel) providing a service within the ir scope of practice and consistent with state and local law.  Clinicians make clinical judgments and are responsible for all services they are permitted to supervise.  Services that require the skills of a therapist, may be appropriately furnished by clinicians, that is, by or under the supervision of qualified physicians/NPPs when their scope of practice, state and local laws allow it and their personal professional training is judged by Medicare contractors as sufficient to provide to the beneficiary ski lls equivalent to a therapist for that service.    COMPLEXITIES are complicating factors that may influence treatment, e.g., they may influence the type, frequency, intensity and/or duration of treatment.  Complexities may be represented by diagnoses (ICD codes), by patient factors such as age, severity, a cuity, multiple conditions, and motivation, or by the patients social circumstances such as the support of a significant other or the availability of transportation to therapy.    A DATE may be in any form (written, stamped or electronic).  The date may be added to the record in any manner and at any time, as long as the dates are accurate.  If they are different, refer to both the date a service was performed and the date the entry to the record was made.  For example, if a physician certifies a plan and fails to date it, staff may add Received Date in writing or with a stamp.  T he received date is valid for certification/re- certification purposes.  Also, if the physician faxes the referral, certification, or re -certification and forgets to date it, the date that prints out on the fax is valid.  If services provided on one date ar e documented on another date, both dates should be documented.    The EPISODE of Outpatient Therapy  For the purposes of therapy policy, an outpatient therapy episode is defined as the period of time, in calendar days, from the first day the patient is under the care of the clinician (e.g., for evaluation or treatment) for the current condition(s) being treated by one therapy discipline (PT, or OT, or SLP) until the last date of service for that discipline in that setting.    During the episode, the beneficiary may be treated for more than one condition; including conditions with an onset after the episode has begun.  For example, a beneficiary receiving PT for a hip fracture who, after the initial treatment session, develops l ow back pain would also be treated under a PT plan of care for rehabilitation of low back pain.  That plan may be modified from the initial plan, or it may be a separate plan specific to the low back pain, but treatment for both conditions concurrently would be considered the same episode of PT treatment.  If that same patient developed a swallowing problem during intubation for the hip surgery, the first day of treatment by the SLP would be a new episode of SLP care.    EVALUATION is a separately payable comprehensive service provided by a clinician, as defined above, that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjectiv e evaluations of patient performance and functional abilities.  Evaluation is warranted e.g., for a new diagnosis or when a condition is treated in a new setting.  These evaluative judgments are essential to development of the plan of care, including goals  and the selection of interventions.    FUNCTIONAL REPORTING, which is required on claims for all outpatient therapy services pursuant to 42CFR410.59, 410.60, and 410.62, uses nonpayable G -codes and related modifiers to convey information about the patients functional status at specified points  during therapy.  (See Pub 100-04, chapter 5, section 10.6)  NOTE : Functional reporting requirements are no longer applicable for claims for dates of service on and after January 1, 2019.  See the NOTE  at the beginning of Section 220.4 for more information about the discontinuation of functional reporting requirements.      RE-EVALUATION provides additional objective information not included in other documentation.  Re -evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significan t improvement, or decline, or change in the patient's condition or functional status that was not anticipated in the plan of care.  Although some state regulations and state practice acts require re -evaluation at specific times, for Medicare payment, reevaluations must also meet Medicare coverage guidelines.  The decision to provide a reevaluation shall be made by a clinician.    INTERVAL of certified treatment (certification interval) consists of 90 calendar days or less, based on an individuals needs.  A physician/NPP may certify a plan of care for an interval length that is less than 90 days.  There may be more than one certifi cation interval in an episode of care.  The certification interval is not the same as a Progress Report period.    MAINTENANCE PROGRAM (MP) means a program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deter ioration due to a disease or illness.    NONPHYSICIAN PRACTITIONERS (NPP) means physician assistants, clinical nurse specialists, and nurse practitioners, who may, if state and local laws permit it, and when appropriate rules are followed, provide, certify or supervise therapy services.    PHYSICIAN with respect to outpatient rehabilitation therapy services means a doctor of medicine, osteopathy (including an osteopathic practitioner), podiatric medicine, or optometry (for low vision rehabilitation only).  Chiropractors and doctors of dental  surgery or dental medicine are not considered physicians for therapy services and may neither refer patients for rehabilitation therapy services nor establish therapy plans of care.    PATIENT, client, resident, and beneficiary are terms used interchangeably to indicate enrolled recipients of Medicare covered services.