Physician Billing Useful Reference | Always Refer to Chapter 15 Medicare Benefit Policy Manual

Physician BillingPhysician Billing

The chapter 15 of Medicare’s Benefit Policy Manual is really a very helpful reference tool. The entire manual is 293 Pages.  I always make this manual as my ultimate reference tool even if I am dealing with the commercial insurance payers. I believe many of these payer’s guidelines, determination and reimbursement policies are very close to that of what’s on Medicare Manual, isn’t it? So here’s a the Chapter 15 of the Manual based on (Rev. 212, 11-06-15). You can use this reference for physician billing and group practice offices.

 

10 – Supplementary Medical Insurance (SMI) Provisions
20 – When Part B Expenses Are Incurred
20.1 – Physician Expense for Surgery, Childbirth, and Treatment for Infertility
20.2 – Physician Expense for Allergy Treatment
20.3 – Artificial Limbs, Braces, and Other Custom Made Items Ordered But Not Furnished

30 – Physician Services and Appropriate Physician Billing

30.1 – Provider-Based Physician Services
30.2 – Teaching Physician Services
30.3 – Interns and Residents
30.4 – Optometrist’s Services
30.5 – Chiropractor’s Services
30.6 – Indian Health Service (IHS) Physician and Nonphysician Services
30.6.1 – Payment for Medicare Part B Services Furnished by Certain IHS Hospitals and Clinics

Search Keyword – Physician Billing

40 – Effect of Beneficiary Agreements Not to Use Medicare Coverage

40.1 – Private Contracts Between Beneficiaries and Physicians/Practitioners
40.2 – General Rules of Private Contracts
40.3 – Effective Date of the Opt-Out Provision
40.4 – Definition of Physician/Practitioner
40.5 – When a Physician or Practitioner Opts Out of Medicare
40.6 – When Payment May be Made to a Beneficiary for Service of an Opt-Out Physician/Practitioner
40.7 – Definition of a Private Contract
40.8 – Requirements of a Private Contract
40.9 – Requirements of the Opt-Out Affidavit
40.10 – Failure to Properly Opt Out
40.11 – Failure to Maintain Opt-Out
40.12 – Actions to Take in Cases of Failure to Maintain Opt-Out
40.13 – Physician/Practitioner Who Has Never Enrolled in Medicare
40.14 – Nonparticipating Physicians or Practitioners Who Opt Out of Medicare
40.15 – Excluded Physicians and Practitioners
40.16 – Relationship Between Opt-Out and Medicare Participation Agreements
40.17 – Participating Physicians and Practitioners
40.18 – Physicians or Practitioners Who Choose to Opt Out of Medicare
40.19 – Opt-Out Relationship to Noncovered Services
40.20 – Maintaining Information on Opt-Out Physicians
40.21 – Informing Medicare Managed Care Plans of the Identity of the Opt-Out Physicians or Practitioners
40.22 – Informing the National Supplier Clearinghouse (NSC) of the Identity of the Opt-Out Physicians or Practitioners
40.23 – Organizations That Furnish Physician or Practitioner Services
40.24 – The Difference Between Advance Beneficiary Notices (ABN) and Private Contracts
40.25 – Private Contracting Rules When Medicare is the Secondary Payer
40.26 – Registration and Identification of Physicians or Practitioners Who Opt Out
40.27 – System Identification
40.28 – Emergency and Urgent Care Situations
40.29 – Definition of Emergency and Urgent Care Situations
40.30 – Denial of Payment to Employers of Opt-Out Physicians and Practitioners
40.31 – Denial of Payment to Beneficiaries and Others
40.32 – Payment for Medically Necessary Services Ordered or Prescribed by an Opt-out physician or Practitioner
40.33 – Mandatory Claims Submission
40.34 – Renewal of Opt-Out
40.35 – Early Termination of Opt-Out
40.36 – Appeals
40.37 – Application to the Medicare Advantage Program
40.38 – Claims Denial Notices to Opt-Out Physicians and Practitioners
40.39 – Claims Denial Notices to Beneficiaries
40.40 – Reporting

Search Keyword – Physician Billing

physician billing

50 – Drugs and Biologicals for Physician Billing

50.1 – Definition of Drug or Biological
50.2 – Determining Self-Administration of Drug or Biological
50.3 – Incident-to Requirements

50.4 – Reasonableness and Necessity

50.4.1 – Approved Use of Drug
50.4.2 – Unlabeled Use of Drug
50.4.3 – Examples of Not Reasonable and Necessary
50.4.4 – Payment for Antigens and Immunizations
50.4.4.1 – Antigens
50.4.4.2 – Immunizations
50.4.5 – Off Lable Use of Anti-Cancer Drugs and Biologicals
50.4.5.1 – Process for Amending the List of Compendia for
Determination of Medically-Accepted Indications for Off-Label
Uses of Drugs and Biologicals in an Anti-Cancer
Chemotherapeutic Regimen
50.4.6 – Less Than Effective Drug
50.4.7 – Denial of Medicare Payment for Compounded Drugs Produced in
Violation of Federal Food, Drug, and Cosmetic Act
50.4.8 – Process for Amending the List of Compendia for Determination
of Medically-Accepted Indications for Off-Label Uses of Drugs and
Biologicals in an Anti-Cancer Chemotherapeutic Regimen
50.5 – Self-Administered Drugs and Biologicals
50.5.1 – Immunosuppressive Drugs
50.5.2 – Erythropoietin (EPO)
50.5.2.1 – Requirements for Medicare Coverage for EPO
50.5.2.2 – Medicare Coverage of Epoetin Alfa (Procrit) for
Preoperative Use
50.5.3 – Oral Anti-Cancer Drugs
50.5.4 – Oral Anti-Nausea (Anti-Emetic) Drugs
50.5.5 – Hemophilia Clotting Factors
50.6 – Coverage of Intravenous Immune Globulin for Treatment of Primary
Immune Deficiency Diseases in the Home

Search Keyword – Physician Billing

60 – Services and Supplies (Incident Physician Billing is here!)

60.1 – Incident To Physician’s Professional Services
60.2 – Services of Nonphysician Personnel Furnished Incident To Physician’s Services
60.3 – Incident To Physician’sServices in Clinic
60.4 – Services Incident to a Physician’s Service to Homebound Patients Under General Physician Supervision
60.4.1 – Definition of Homebound Patient Under the Medicare Home
Health (HH) Benefit

70 – Sleep Disorder Clinics

80 – Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic
Tests

Search Keyword – Physician Billing

80.1 – Clinical Laboratory Services

80.1.1 – Certification Changes
80.1.2 – Carrier Contacts With Independent Clinical Laboratories
80.1.3 – Independent Laboratory Service to a Patient in the Patient’s Home or an Institution
80.2 – Psychological and Neuropsychological Tests
80.3 – Audiology Services
80.3.1 – Definition of Qualified Audiologist
80.4 – Coverage of Portable X-Ray Services Not Under the Direct Supervision of a Physician
80.4.1 – Diagnostic X-Ray Tests
80.4.2 – Applicability of Health and Safety Standards
80.4.3 – Scope of Portable X-Ray Benefit
80.4.4 – Exclusions From Coverage as Portable X-Ray Services
80.4.5 – Electrocardiograms
80.5 – Bone Mass Measurements (BMMs)
80.5.1 – Background
80.5.2 – Authority
80.5.3 – Definition
80.5.4 – Conditions for Coverage
80.5.5 – Frequency Standards
80.5.6 – Beneficiaries Who May be Covered
80.5.7 – Noncovered BMMs
80.5.8 – Claims Processing
80.5.9 – National Coverage Determinations (NCDs)
80.6 – Requirements for Ordering and Following Orders for Diagnostic Tests
80.6.1 – Definitions
80.6.2 – Interpreting Physician Determines a Different Diagnostic Test is Appropriate
80.6.3 – Rules for Testing Facility to Furnish Additional Tests
80.6.4 – Rules for Testing Facility Interpreting Physician to Furnish Different or Additional Tests
80.6.5 – Surgical/Cytopathology Exception

90 – X-Ray, Radium, and Radioactive Isotope Therapy

100 – Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations

Search Keyword – Physician Billing

110 – Durable Medical Equipment – General

110.1 – Definition of Durable Medical Equipment
110.2 – Repairs, Maintenance, Replacement, and Delivery
110.3 – Coverage of Supplies and Accessories
110.4 – Miscellaneous Issues Included in the Coverage of Equipment
110.5 – Incurred Expense Dates for Durable Medical Equipment
110.6 – Determining Months for Which Periodic Payments May Be Made for
Equipment Used in an Institution
110.7 – No Payment for Purchased Equipment Delivered Outside the United States
or Before Beneficiary’s Coverage Began

120 – Prosthetic Devices

130 – Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes

140 – Therapeutic Shoes for Individuals with Diabetes

150 – Dental Services

150.1 – Treatment of Temporomandibular Joint (TMJ) Syndrome

160 – Clinical Psychologist Services

170 – Clinical Social Worker (CSW) Services

180 – Nurse-Midwife (CNM) Services

190 – Physician Assistant (PA) Services

200 – Nurse Practitioner (NP) Services

210 – Clinical Nurse Specialist (CNS) Services

 

Search Keyword – Physician Billing

220 – Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance

220.1 – Conditions of Coverage and Payment for Outpatient Physical Therapy,
Occupational Therapy, or Speech-Language Pathology Services
220.1.1 – Care of a Physician/Nonphysician Practitioner (NPP)
220.1.2 – Plans of Care for Outpatient Physical Therapy, Occupational
Therapy, or Speech-Language Pathology Services
220.1.3 – Certification and Recertification of Need for Treatment and
Therapy Plans of Care
220.1.4 – Requirement That Services Be Furnished on an Outpatient Basis
220.2 – Reasonable and Necessary Outpatient Rehabilitation Therapy Services
220.3 – Documentation Requirements for Therapy Services
220.4 – Functional Reporting

230 – Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology

230.1 – Practice of Physical Therapy
230.2 – Practice of Occupational Therapy
230.3 – Practice of Speech-Language Pathology
230.4 – Services Furnished by a Therapist in Private Practice (TPP)
230.5 – Physical Therapy, Occupational Therapy and Speech-Language Pathology Services Provided Incident to the Services of Physicians and Nonphysician Practitioners (NPP)
230.6 – Therapy Services Furnished Under Arrangements With Providers and Clinics
231 – Pulmonary Rehabilitation (PR) Program Services Furnished on or After January 1, 2010
232 – Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Services Furnished On or After January 1, 2010

240 – Chiropractic Services – General

240.1 – Coverage of Chiropractic Services
240.1.1 – Manual Manipulation
240.1.2 – Subluxation May Be Demonstrated by X-Ray or Physician’s Exam
240.1.3 – Necessity for Treatment
240.1.4 – Location of Subluxation
240.1.5 – Treatment Parameters

Search Keyword – Physician Billing

250 – Medical and Other Health Services Furnished to Inpatients of Hospitals and Skilled Nursing Facilities

260 – Ambulatory Surgical Center Services

260.1 – Definition of Ambulatory Surgical Center (ASC)
260.2 – Ambulatory Surgical Center Services
260.3 – Services Furnished in ASCs Which are Not ASC Facility Services
260.4 – Coverage of Services in ASCs, Which are Not ASC Services
260.5 – List of Covered Ambulatory Surgical Center Procedures
260.5.1 – Nature and Applicability of ASC List
260.5.2 – Nomenclature and Organization of the List
260.5.3 – Rebundling of CPT Codes

270 – Telehealth Services

270.1 – Eligibility Criteria
270.2 – List of Medicare Telehealth Services
270.3 – Conditions of Payment
270.4 – Payment – Physician/Practitioner at a Distant Site
270.4.1 – Payment for ESRD-Related Services as a Telehealth Service
270.4.2 – Payment for Subsequent Hospital Care Services and Subsequent Nursing Facility Care Services as Telehealth Services
270.4.3 – Payment for Diabetes Self Management Training (DSMT) as a Telehealth Service
270.5 – Originating Site Facility Fee Payment Methodology
270.5.1 – Originating Site Facility Fee Payment (ESRD-Related Services

Search Keyword – Physician Billing

280 – Preventive and Screening Services

280.1 – Glaucoma Screening
280.2 – Colorectal Cancer Screening
280.2.1 – Covered Services and HCPCS Codes
280.2.2 – Coverage Criteria
280.2.3 – Determining Whether or Not the Beneficiary is at High Risk for Developing Colorectal Cancer
280.2.4 – Determining Frequency Standards
280.2.5 – Noncovered Services
280.3 – Screening Mammography
280.4 – Screening Pap Smears
280.5 – Annual Wellness Visit (AWV) Providing Personalized Prevention Plan Services (PPPS)
280.5.1 – Advance Care Planning (ACP) Furnished as an Optional Element with an Annual Wellness Visit (AWV) upon Agreement with the Patient

290 – Foot Care

Search Keyword – Physician Billing

300 – Diabetes Self-Management Training Services

300.1 – Beneficiaries Eligible for Coverage and Definition of Diabetes
300.2 – Certified Providers
300.3 – Frequency of Training
300.4 – Coverage Requirements for Individual Training
300.4.1- Incident -To Provision
300.5 – Payment for DSMT
300.5.1 – Special Claims Processing Instructions FIs
310 – Kidney Disease Patient Education Services
310.1 – Beneficiaries Eligible for Coverage
310.2 – Qualified Person
310.3 – Limitations for Coverage
310.4 – Standards for Content
310.5 – Outcomes Assessment

Search Keyword – Physician Billing

Medicare Benefit Policy Manual Covered Medical and Other Health Services Chapter 15 Rev 212 11-06-15