(Medicare Claims Processing Manual)

The teaching CRNA (not under the medical direction of a physician), can be paid for his or her involvement in each of two concurrent cases with student nurse anesthetists; allow payment at the regular fee schedule rate. The teaching CRNA reports the anesth esia service using the QZ  modifier.   To bill the anesthesia base units, the teaching CRNA must be present with the student nurse anesthetist during pre and post anesthesia care for each of the two  cases.  To bill anesthesia time for each case, the teaching CRNA must continue to devote his or her time to the two concurrent cases and not be involved in other activities. The teaching CRNA can decide how to allocate his or her time to optimize patient c are in the two cases based on the complexity of the anesthesia cases, the experience and skills of the student nurse anesthetists, and the patients health status and other  factors.  The teaching CRNA must document his or her involvement in the cases with the student nurse  anesthetists.   150 - Clinical Social Worker (CSW) Services (Rev. 2656, Issuance: 02- 07-13, Effective: 02- 19-13, Implementation: 02- 19-13)  See Medicare Benefit Policy Manual, Chapter 15, for coverage requirements.  Assignment of benefits is required.   Payment is at 75 percent of the physician fee schedule.  CSWs are identified on the provider file by specialty code 80 and provider type 56.  Medicare applies the outpatient mental health limitation to all covered therapeutic services furnished by qualified CSWs.  Refer to 210, below, for a discussion of the outpatient mental health limitation.   160 - Independent Psychologist Services  (Rev. 1, 10- 01-03) B3-2150, B3- 2070.2  See the Medicare Benefit Policy Manual, Chapter 15, for coverage requirements.  There are a number of types of psychologists.  Educational psychologists engage in identifying and treating education- related issues.  In contrast, counseling psychologists provide services that include a broader realm including phobias, familial issues, e tc.  Psychometrists are psychologists who have been trained to administer and interpret tests.  However, clinical psychologists are defined as a provider of diagnostic and therapeutic services.  Because of the differences in services provided, services pro vided by psychologists who do not provide clinical services are subject to different billing guidelines.  One service often provided by nonclinical psychologist is diagnostic testing.  NOTE: Diagnostic psychological testing services performed by persons who meet these requirements are covered as other diagnostic tests.  When, however, the psychologist is not practicing independently, but is on the staff of an institution, agency, or clinic, that entity bills for the diagnostic services.   Expenses for such testing are not subject to the payment limitation on treatment for mental, psychoneurotic, and personality disorders.  Independent psychologists are not required by law to accept assignment when performing psychological tests.  However, regardless of whether the psychologist accepts assignment, he or she must report on the claim form the name and address of the physician who ordered the test.   160.1 - Payment  (Rev. 1, 10- 01-03)  Diagnostic testing services are not subject to the outpatient mental health limitation.  Refer to 210, below, for a discussion of the outpatient mental health limitation. The diagnostic testing services performed by a psychologist (who is not a clinical psychologist) practicing independently of an institution, agency, or physicians office are covered as other diagnostic tests if a physician orders such testing.  Medicare c overs this type of testing as an outpatient service if furnished by any psychologist who is licensed or certified to practice psychology in the State or jurisdiction where he or she is furnishing services or, if the jurisdiction does not issue licenses, if  provided by any practicing psychologist.  (It is CMS understanding that all States, the District of Columbia, and Puerto Rico license psychologists, but that some trust territories do not.  Examples of psychologists, other than clinical psychologists, whose services are covered under this provision include, but are not limited to, educational psychologists and counseling psychologists.)   To determine whether the diagnostic psychological testing services of a particular independent psychologist are covered under Part B in States which have statutory licensure or certification, A/B MACs (B) must secure from the appropriate State agency a current listing of psychologists holding the required credentials.  In States or territories which lack statutory licensing and certification, A/B MACs (B) must check individual qualifications as claims are submitted.  Possible reference sources are the natio nal directory of membership of the American Psychological Association, which provides data about the educational background of individuals and indicates which members are board- certified, and records and directories of the State or territorial psychologica l association.  If qualification is dependent on a doctoral degree from a currently accredited program, A/B MACs (B) must verify the date of accreditation of the school involved, since such accreditation is not retroactive.  If the reference sources listed  above do not provide enough information (e.g., the psychologist is not a member of the association), A/B MACs (B) must contact the psychologist personally for the required information.  A/B MACs (B) may wish to maintain a continuing list of psychologists whose qualifications have been verified.   Medicare excludes expenses for diagnostic testing from the payment limitation on treatment for mental/psychoneurotic/personality disorders.   A/B MACs (B)  must identify the independent psychologists choice whether or not to accept assignment when performing psychological tests.  A/B MACs (B) must accept an independent psychologist claim only if the psychologist reports the name/UPIN of the physician who ordered a test.   A/B MACs (B) pay nonparticipating independent psychologists at 95 percent of the physician fee schedule allowed amount.  A/B MACs (B) pay participating independent psychologists at 100 percent of the physician fee schedule allowed amount.   Independent psychologists are identified on the provider file by specialty code 62 and provider type 35.   170 - Clinical Psychologist Services (Rev. 1, 10- 01-03) B3-2150  See Medicare Benefit Policy Manual, Chapter 15, for general coverage requirements.   Direct payment may be made under Part B for professional services.  However, services furnished incident to the professional services of CPs to hospital patients remain bundled.  Therefore, payment must continue to be made to the hospital (by the A/B MAC ( A)) for such incident to services.  170.1 - Payment  (Rev. 2656, Issuance: 02- 07-13, Effective: 02- 19-13, Implementation: 02- 19-13)  All covered therapeutic services furnished by qualified CPs are subject to the outpatient mental health treatment limitation (the limitation).  Generally, the limitation does not apply to diagnostic services.  Refer to 210 below for a discussion of the outpatient mental health treatment limitation.   Payment for the services of CPs is made on the basis of a fee schedule or the actual charge, whichever is less, and only on the basis of assignment.  CPs are identified by specialty code 68 and provider type 27.   180 - Care Plan Oversight Services  (Rev. 999, Issued:  07- 14-06; Effective:  01 -01-05; Implementation:  10 -02-06) The Medicare Benefit Policy Manual, Chapter 15, contains requirements for coverage for medical and other health services including those of physicians and non- physician practitioners.  Care plan oversight (CPO) is the physician supervision of a patient receiving complex and/or multidisciplinary care as part of Medicare -covered services provided by a participating home health agency or Medicare approved hospice.  CPO services require complex or multidisciplinary care modalities involving:  Regular physician development and/or revision of care plans;   Review of subsequent reports of patient status;   Review of related laboratory and other studies;   Communication with other health professionals not employed in the same practice who are involved in the patients care;   Integration of new information into the medical treatment plan; and/or   Adjustment of medical therapy.  The CPO services require recurrent physician supervision of a patient involving 30 or more minutes of the physicians time per month.  Services not countable toward the 30 minutes threshold that must be provided in order to bill for CPO include, but are not limited to:   Time associated with discussions with the patient, his or her family or friends to adjust medication or treatment;  Time spent by staff getting or filing charts;   Travel time; and/or   Physicians time spent telephoning prescriptions into the pharmacist unless the telephone conversation involves discussions of pharmaceutical therapies.  Implicit in the concept of CPO is the expectation that the physician has coordinated an aspect of the patients care with the home health agency or hospice during the month for which CPO services were billed.  The physician who bills for CPO must be the sa me physician who signs the plan of care.  Nurse practitioners, physician assistants, and clinical nurse specialists, practicing within the scope of State law, may bill for care plan oversight.  These non- physician practitioners must have been providing ongoing care for the beneficiary through evaluation and management services.  These non -physician practitioners may not bill for CPO if they have been involved only with the delivery of the Medicare -covered home health or hospice service.  A. Home Health CPO  Non-physician practitioners can perform CPO only if the physician signing the plan of care provides regular ongoing care under the same plan of care as does the NPP billing for CPO and either:   The physician and NPP are part of the same group practice; or   If the NPP is a nurse practitioner or clinical nurse specialist, the physician signing the plan of care also has a collaborative agreement with the NPP; or   If the NPP is a physician assistant, the physician signing the plan of care is also the physician who provides general supervision of physician assistant services for the practice.  Billing may be made for care plan oversight services furnished by an NPP when:  The NPP providing the care plan oversight has seen and examined the patient;   The NPP providing care plan oversight is not functioning as a consultant whose participation is limited to a single medical condition rather than multidisciplinary coordination of care; and  The NPP providing care plan oversight integrates his or her care with that of the physician who signed the plan of care. NPPs may not certify the beneficiary for home health care.  B. Hospice CPO  The attending physician or nurse practitioner (who has been designated as the attending physician)  may bill for hospice CPO when they are acting as an attending physician.  An attending physician is one who has been identified by the individual, at the time he/she elects hospice coverage, as having the most significant role in the determination and delivery of their medical care.  They are not employed nor paid by the hospice . The care plan oversight services are billed using Form CMS -1500 or electronic  equivalent.  For additional information on hospice CPO, see Chapter 11, 40.1.3.1 of this manual .  180.1 - Care Plan Oversight Billing Requirements  (Rev. 999, Issued:  07- 14-06; Effective:  01 -01-05; Implementation:  10 -02-06)  A. Codes for Which Separate Payment May Be Made   Effective January 1, 1995, separate payment may be made for CPO oversight services for 30 minutes or more if the requirements specified in the Medicare Benefits Policy Manual, Chapter 15 are met.    Providers billing for CPO must submit the claim with no other services billed on that claim and may bill only after the end of the month in which the CPO services were rendered.  CPO services may not be billed across calendar months and should be submitted  (and paid) only for one unit of service.   Physicians may bill and be paid separately for CPO services only if all the criteria in the Medicare Benefit Policy Manual, Chapter 15 are met.   B. Physician Certification and Recertification of Home Health Plans of Care   Effective 2001, two new HCPCS codes for the certification and recertification  and development of plans of care for Medicare -covered home health services were created. See the Medicare General Information, Eligibility, and Entitlement Manual, Pub. 100- 01,  Chapter 4, Physician Certification and Recertification of Services , 10 -60, and the Medicare Benefit Policy Manual, Pub. 100- 02, Chapter 7, Home Health Services, 30.   The home health agency certification code can be billed only when the patient has not received Medicare -covered home health services for at least 60 days.  The home health agency recertification code is used after a patient has received services for at least 60 days (or one certification period) when the physician signs the certification after the initial certification period.  The home health agency recertification code will be reported only once every 60 days, except in the rare situation when the patient  starts a new episode before 60 days elapses and requires a new plan of care to start a new episode.