(Medicare Benefit Policy Manual)

b. Physician Recertification Requirements .--     Signature  The physician recertification must be signed by a physician who is treating the patient and has knowledge of the patients response to treatment.     Timing  Recertifications are required at intervals established by the provider, but no less frequently than every 60 days following the initial IOP certification.      Content  The recertification must specify that the patient requires a minimum of 9 hours of mental health treatment services per week and describe the following:      The patients response to the therapeutic interventions provided by the IOP;     The patients psychiatric symptoms (including SUD) that continue to require intensive treatment; and     Treatment goals for coordination of services to facilitate discharge from the IOP.     c. Treatment Plan.--An intensive outpatient program is active treatment pursuant to an individualized treatment plan, prescribed and signed by a physician, which identifies treatment goals, describes a coordination of services, is structured to meet the particular needs of the patient, and includes a multidisciplinary team approach to patient care.  The treatment goals described in the treatment plan should directly address the presenting symptoms and are the basis for evaluating the patients response to treatment.  Treatment goals should be designed to measure the patients response to active treatment.  The plan should document ongoing efforts to restore the individual patient to a higher level of functioning that would permit discharge from the program, or reflect the continued need for the intensity of the active therapy to maintain the individuals condition and functional level and to prevent relapse or hospitalization.  Activities that are primarily recreational and diversionary, or provide only a level of functional support that does not treat the serious presenting psychiatric symptoms (including SUD) placing the patient at risk, do not qualify as intensive outpatient program services.    d. Progress Notes.--Section 1833(e) of the Social Security Act prevents Medicare from paying for services unless necessary and sufficient information is submitted that shows that services were provided and to determine the amounts due.  A provider may submit progress notes to document the services that have been provided.  The progress note should include a description of the nature of the treatment service, the patients response to the therapeutic intervention and its relation to the goals indicated in the treatment plan.    See the Medicare Claims Processing Manual, Chapter 4, Hospital Outpatient Services, 261 for billing instructions for intensive outpatient program services.  70.5 - Laboratory Services Furnished to Nonhospital Patients by Hospital Laboratory  (Rev. 82; Issued:  02-08- 08; Effective:  01 -01-08; Implementation:  03 -10-08)  A nonhospital patient is an individual who is neither an inpatient nor outpatient of the hospital furnishing the service.  (See the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 1, Inpatient Hospital Services, section 10, for the definition of a hospital inpatient and section 20.1 for the definition of a hospital outpatient).  Nonhospital patients primarily are individuals from whom a specimen had been taken and sent to the hospital for analysis and the patient does not receive hospital outpatient services on the same day.  For all hospitals except CAHs and Maryland waiver hospitals, if a beneficiary receives hospital outpatient services on the same day as a specimen collection and laboratory test, then the patient is considered to be a registered hospital outpatient and cannot be considered to be a non-patient on that day for purposes of the specimen collection and laboratory test.  However if the non-CAH or Maryland waiver hospital only collects or draws a specimen from the beneficiary and the bene ficiary does not also receive hospital outpatient services on that day, the hospital may choose to register the beneficiary as an outpatient for the specimen collection or bill for these services as non- patient on the 14X bill type.  For CAHs, payment for clinical diagnostic laboratory tests is made at 101 percent of reasonable cost, only if the individuals are outpatients of the CAH, as defined in 42 CFR 410.2, and are physically present in the CAH at the time the specimens are collec ted.  Clinical diagnostic laboratory tests performed for persons who are not physically present (non- patients) at the CAH when the specimens are collected are made in accordance with the provisions of sections 1833(a)(1)(D) and 1833(a)(2)(D) of the Social Security Act.  See also 42 CFR 413.70(b)(iii).  Similarly, for Maryland waiver hospitals, the waiver is limited to services to inpatients and registered outpatients as defined in 42 CFR 410.2.  Therefore payment for non -patients (specimen only, TOB 14X) who are not registered outpatients at the time of specimen collection will be made on the clinical diagnostic laboratory fee schedule.  Such services are covered to the extent appropriate.   See the Medicare Claims Processing Manual, Pub. 100- 04, Chapter 16, Laboratory Services from Independent Labs, Physicians, and Providers, section 40.3, for billing and payment of clinical diagnostic laboratory services for patients and non- patients.   80 - Rental and Purchase of Durable Medical Equipment  (Rev. 1, 10- 01-03) A3-3113, HO -235, HHA -220  Rental and purchase of DME is covered under Part B for use in a patients home. DME rendered to inpatients of a SNF or hospital is covered as part of the prospective payment system and not separately payable.  See the Medicare Benefit Policy Manual, Chapter 15, 110 for coverage of Durable Medical Equipment and the Medicare Claims Processing Manual, Chapter 20, Durable Medical Equipment, Prosthetics and Orthotics, and Supplies (DMEPOS), for special billing i nstructions.  90 - Services of Interns And Residents  (Rev. 1, 10- 01-03) A3-3115, HO -237  A.  General   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., individuals 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 reimbursement.  As a general rule, services of interns and residents are paid as provider services by the A/B MAC (A) .  B.  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, this includes services furnished in a setting which i s not part of the provider where a hospital has agreed to incur all or substantially all of the costs of training in the nonprovider facility.  Providers are required to notify the A/B MAC (B) of such agreements.  Where the provider does not incur all or s ubstantially all of the training costs and the services are performed by a licensed physician, the services are reimbursable on a reasonable charge basis by the A/B MAC (B).  Prior to July 1, 1987, the covered services of interns and residents were reimbur sed by the A/B MAC (B) on a reasonable charge basis as physician services if furnished by a licensed physician off the provider premises regardless of who incurred the training costs.  C.  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 physicians services and paid on a reasonable cha rge basis where the requirements in 1 and 2, 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 w here they have their training program, are covered as physicians services and paid on a reasonable charge basis where the following criteria are met:   1. The services are identifiable physicians services, the nature of which requires performance by a physician in person and which contributes to the diagnosis or treatment of the patients condition;   2. The intern or resident is fully licensed to practice medicine, osteopathy, dentistry or podiatry by the State in which the services are performed; and   3. 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.   Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12421BP  12/21/2023 January 2024 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/02/2024 13488  R12425BP  12/21/2023 Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92 - Additional Publication Update 01/02/2024 13496  R10541BP  12/31/2020 January 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS  01/04/2021 12020  R267BP  02/04/2020 January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/06/2020 11605  R266BP  01/15/2020 January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS) - No Longer Sensitive/Controversial  Rescinded and Replaced by Transmittal 267 01/15/2020 11605