(Medicare Benefit Policy Manual)

Medicare Benefit Policy Manual  Chapter 6 - Hospital Services Covered Under Part B   Table of Contents  (Rev. 12421; Issued;  12-21-23) (Rev. 12425; Issued; 12-21-23)  Transmittals for Chapter 6   10 - Medical and Other Health Services Furnished to Inpatients of Participating Hospitals  10.1 - Reasonable and Necessary Part A Hospital Inpatient Claim Denials  10.2  Other Circumstances in Which Payment Cannot Be Made Under Part A  10.3  Hospital Inpatient Services Paid Only Under Part B  20 - Outpatient Hospital Services  20.1 - Limitation on Coverage of Certain Services Furnished to Hospital Outpatients  20.1.1 - General Rule  20.1.2 - Exception to Limitation  20.2 - Outpatient Defined  20.3 - Encounter Defined  20.4 - Outpatient Diagnostic  Services  20.4.1 - Diagnostic Services Defined 20.4.2 - Reserved  20.4.3 - Coverage of Outpatient Diagnostic Services Furnished on or Before December 31, 2009  20.4.4 - Coverage of Outpatient Diagnostic Services Furnished on or After January 1, 2010  20.4.5 - Outpatient Diagnostic Services Under Arrangements  20.5  Outpatient Therapeutic Services  20.5.1 - Coverage of Outpatient Therapeutic Services Incident to a Physician's Services Furnished on or After August 1, 2000 and Before January 1, 2010 20.5.2 - Coverage of Outpatient Therapeutic Services Incident to a Physician's Services Furnished on January 1, 2010 through December 31, 2019                         20.5.3 - Coverage of Outpatient Therapeutic Services Incident to a              Physicians Service Furnished on or After January 1, 2020 -  Changes to            Supervision Requirements                         20.5.4 Coverage of Outpatient Therapeutic Services Incident to a                          Physicians    Service Furnished on or After January 1, 2024  Changes to                        Direct Supervision Requirements for Pulmonary, Cardiac and Intensitv                          Cardiac   Rehabilitation   20.6 -  Outpatient Observation Services  30 - Drugs and Biologicals  40 - Other Covered Services and Items  50 - Sleep Disorder Clinics  60 - Intermittent Peritoneal Dialysis Services  70 - Outpatient Hospital Psychiatric Services  70.1 -  General  70.2 -  Coverage Criteria for Outpatient Hospital Psychiatric Services  70.3 -  Partial Hospitalization Services   70.4 -  Intensive Outpatient Services   70.5 -  Laboratory Services Furnished to Nonhospital Patients by Hospital Laboratory  80 - Rental and Purchase of Durable Medical Equipment  90 - Services of Interns And Residents  10 - Medical and Other Health Services Furnished to Inpatients of Participating Hospitals  (Rev. 182, Issued: 03- 21-14, Effective: 10 -01-13, Implementation: 04- 21-14)  Payment may be made under Part B for physician services and for the nonphysician medical and other health services as provided in this section when furnished by a participating hospital (either directly or under arrangements) to an inpatient of the hospital, but only if payment for these services cannot be made under Part A.  This policy applies to all hospitals and critical access hospitals (CAHs) participating in Medicare, including those paid under a prospective payment system or alternative payment methodology such as State cost control systems, and to emergency hospital services furnished by nonparticipating hospitals.  In this section, the term hospital includes all hospitals and CAHs, regardless of payment methodology, unless otherwise specified.   For services to be covered under Part A or Part B, a hospital must furnish nonphysician services to its inpatients directly or under arrangements (see chapter 16, 170 of this manual, Inpatient Hospital or SNF Services Not Delivered Directly or Under Arrangement by the Provider).  A nonphysician service is one which does not meet the criteria defining physicians services specifically provided for in regulation at 42 CFR 415.102. Services "incident to" physicians services (except for the services of nurs e anesthetists employed by anesthesiologists) are nonphysician services for purposes of this provision.  10.1 - Reasonable and Necessary Part A Hospital Inpatient Claim Denials  (Rev. 182, Issued: 03- 21-14, Effective: 10 -01-13, Implementation: 04- 21-14)  If a Medicare Part A claim for inpatient hospital services is denied because the inpatient admission was not reasonable and necessary, or if a hospital determines under 42 CFR 482.30(d) or 485.641 after a beneficiary is discharged that the beneficiarys inpatient admission was not reasonable and necessary, and if waiver of liability payment is not made, the hospital may be paid for the following Part B inpatient services that would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient rather than admitted as an inpatient, provided the beneficiary is enrolled in Medicare Part B:   1) Part B services paid under the outpatient prospective payment system (OPPS), excluding observation services and hospital outpatient visits that require an outpatient status.  Hospitals that are excluded from payment under the OPPS are instead paid under their alternative payment methodology (e.g., reasonable cost, all inclusive rate, or Maryland waiver) for the services that are otherwise payable under the OPPS.  2) The following services excluded from OPPS payment, that are instead paid under the respective Part B fee schedules or prospectively determined rates for which payment is made for these services when provided to hospital outpatients:   a. Physical therapy services, speech -language pathology services, and occupational therapy services (see chapter 15, 220 and 230 of this manual, Covered Medical and Other Health Services,).   b. Ambulance services.   c. Prosthetic devices, prosthetic supplies, and orthotic devices paid under the DMEPOS fee schedule (excludes implantable prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags and supplies directl y related to colostomy care) and replacement of such devices).   d. Durable medical equipment supplied by the hospital for the patient to take home, except durable medical equipment that is implantable.   e. Certain clinical diagnostic laboratory services.   f. Screening and diagnostic mammography services.   g. Annual wellness visit providing personalized prevention plan services.   Hospitals may also be paid under Part B for services included in the payment window prior to the point of inpatient admission for outpatient services treated as inpatient services (see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 4, 10.12, Pay ment Window for Outpatient Services Treated as Inpatient Services), including services requiring an outpatient status.  The hospital can only bill for services that it provided directly or under arrangement in accordance with Part B payment rules.  Outpat ient therapeutic services furnished at an entity that is wholly owned or wholly operated by the hospital and is not part of the hospital (such as a physicians office), may not be billed by the hospital to Part B.  Reference labs may be billed only if the referring laboratory does not bill for the laboratory test (see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 16, 40.1, Laboratories Billing for Referred Tests).   The services billed to Part B must be reasonable and necessary and must meet all applicable Part B coverage and payment conditions.  Claims for Part B services submitted following a reasonable and necessary Part A claim denial or hospital utilization revie w determination must be filed no later than the close of the period ending 12 months or 1 calendar year after the date of service (see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 1, 70 Time Limitations for Filing Part A and Part B Claims).  See Pub. 100- 04, Medicare Claims Processing Manual, chapter 4, 240 for required bill types.  10.2 - Other Circumstances in Which Payment Cannot Be Made Under Part A (Rev. 182, Issued: 03- 21-14, Effective: 10 -01-13, Implementation: 04- 21-14)  Part B payment could be made to a hospital for the medical and other health services listed in this section for inpatients enrolled in Part B if:   No Part A prospective payment is made at all for the hospital stay because of patient exhaustion of benefit days before or during the admission; or    The patient was not otherwise eligible for or entitled to coverage under Part A (see chapter 16, 180 of this manual for services received as a result of non -covered services).   Beginning in 2014, for hospitals paid under the OPPS these Part B inpatient services are separately payable under Part B, and are excluded from OPPS packaging if the primary service with which the service would otherwise be bundled is not a payable Part B inpatient service.   The following inpatient services are payable under the OPPS:    Diagnostic x- ray tests, diagnostic laboratory tests, and other diagnostic tests;    X-ray, radium, and radioactive isotope therapy, including materials and services of technicians;    Acute dialysis of a hospital inpatient with or without end stage renal disease (ESRD).  The charge for hemodialysis is a charge for the use of a prosthetic device, billed in accordance with Pub. 100- 04, Medicare Claims Processing Manual, Chapter 4, 200.2, Hospital Dialysis Services for Patients With and Without End Stage Renal Disease (ESRD).    Screening pap smears;    Influenza, pneumococcal pneumonia, and hepatitis B vaccines;    Colorectal screening;    Bone mass measurements;    Prostate screening;    Hemophilia clotting factors for hemophilia patients competent to use these factors without supervision;    Immunosuppressive drugs;    Oral anti -cancer drugs;    Oral drug prescribed for use as an acute anti -emetic used as part of an anti -cancer chemotherapeutic regimen; and    Epoetin Alfa (EPO) that is not covered under the ESRD benefit.  The following inpatient services are payable under the non- OPPS Part B fee schedules or prospectively determined rates listed:   Surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations (DMEPOS fee schedule);    Prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), including replacement of such devices and including one pair of conventional eyeglasses o r contact lenses furnished subsequent to each cataract surgery with insertion of intraocular lens (DMEPOS fee schedule, except for implantable prosthetic devices paid at the applicable rate under Pub. 100- 04, Medicare Claims Processing Manual, Chapter 4, 240.3, Inpatient Part B Hospital Services -   Implantable Prosthetic Devices);    Leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes including replacements if required because of a change in the patients physical condition (DMEPOS fee schedule);    Physical therapy services, speech -language pathology services, and occupational therapy services (see Chapter 15, 220 and 230 of this manual, Covered Medical and Other Health Services) (applicable rate based on the Medicare Physician Fee Schedule);    Ambulance services (ambulance fee schedule); and    Screening mammography services (Medicare Physician Fee Schedule).   Hospitals may also be paid under Part B for services included in the payment window prior to the point of inpatient admission for outpatient services treated as inpatient services (see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 4, 10.12, Pay ment Window for Outpatient Services Treated as Inpatient Services), including services requiring an outpatient status.  The hospital can only bill for services that it provided directly or under arrangement in accordance with Part B payment rules.  Outpat ient therapeutic services furnished at an entity that is wholly owned or wholly operated by the hospital and is not part of the hospital (such as a physicians office), may not be billed by the hospital to Part B.  Reference labs may be billed only if the referring laboratory does not bill for the laboratory test (see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 16, 40.1, Laboratories Billing for Referred Tests).   The services billed to Part B must be reasonable and necessary and must meet all applicable Part B coverage and payment conditions.  Claims for these services must be filed no later than the close of the period ending 12 months or 1 calendar year after the date of service (see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 1, 70, Time Limitations for Filing Part A and Part B Claims).  See Pub. 100 -04, Medicare Claims Processing Manual, chap ter 4, 240 for required bill types.  10.3 - Hospital Inpatient Services Paid Only Under Part B  (Rev. 182, Issued: 03- 21-14, Effective: 10 -01-13, Implementation: 04- 21-14)