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Medicare Benefit Policy ManualChapter 15 - Medical and Other Health ServicesCrosswalkNewChap.NewSect.Int.Pub. 131510B3-20001520B3-2005When Part B Expenses Are Incurred1520.1B3-2005.lPhysicians’ Expense for Surgery, Childbirth, and Treatment forInfertility1520.2B3-2005.2,B3-4145Physicians’ Expense for Allergy Treatment1520.3B3-2005.3Artificial Limbs, Braces, and Other Custom Made Items OrderedBut Not Furnished1530B3-2020,B3-4142,B3-15513Physicians’ Services1530.1B3-2020.6,B3-8000-8099Provider-Based Physician Services1530.2B3-2020.7,B3-8210,B3-15016Teaching Physician Services1530.3B3-2020.8Interns and Residents1530.4B3-2020.25Optometrist’s ServicesA3-3145A3-3115CarrierPub. 14PMsOtherDescriptionHO-245Supplementary Medical Insurance (Part B) Provisions
NewChap.NewSect.Int.Pub. 13CarrierPub. 14PMs1530.51530.61540B3-30441540.1B3-3044.1Private Contracts Between Beneficiaries andPhysicians/Practitioners1540.2B3-3044.2General Rules of Private Contracts1540.3B3-3044.3Effective Date of the Opt-Out Provision1540.4B3-3044.4Definition of Physician/Practitioner1540.5B3-3044.5When a Physician or Practitioner Opts Out of Medicare1540.6B3-3044.6When Payment May be Made to a Beneficiary for Service of anOpt-Out Physician/Practitioner1540.7B3-3044.7Definition of a Private Contract1540.8B3-3044.8Requirements of a Private Contract1540.9B3-3044.9Requirements of the Opt-Out Affidavit1540.10B3-3044.10Failure to Properly Opt Out1540.11B3-3044.11Failure to Maintain Opt-Out1540.12B3-3044.12Actions to Take in Cases of Failure to Maintain Opt-Out1540.13B3-3044.13Physician/Practitioner Who Has Never Enrolled in MedicareB3-2020.26OtherDescriptionChiropractor’s ServicesAB-02-150Indian Health Service (IHS) Physician and NonphysicianServicesB-97-17Effect of Beneficiary Agreements Not To Use MedicareCoverage
NewChap.NewSect.Int.Pub. 13CarrierPub. ating Physicians or Practitioners Who Opt Out ofMedicare1540.15B3-3044.15Excluded Physicians and Practitioners1540.16B3-3044.16Relationship Between Opt-Out and Medicare ing Physicians and Practitioners1540.18B3-3044.18Physicians or Practitioners Who Choose to Opt Out of Medicare1540.19B3-3044.19Relationship to Noncovered Services1540.20B3-3044.20Maintaining Information on Opt-Out Physicians1540.21B3-3044.21Informing Managed Care Plans of the Identity of the Opt-OutPhysicians or Practitioners1540.22B3-3044.22Informing the National Supplier Clearinghouse (NSC) of theIdentity of the Opt-Out Physicians or Practitioners1540.23B3-3044.23Organizations That Furnish Physician or Practitioner Services1540.24B3-3044.24The Difference Between Advance Beneficiary Notices (ABN)and Private Contracts1540.25B3-3044.25Private Contracting Rules When Medicare is the Secondary Payer1540.26B3-3044.26Registration and Identification of Physicians or Practitioners WhoOpt Out1540.27B3-3044.27System Identification1540.28B3-3044.28Emergency and Urgent Care Situations
NewChap.NewSect.Int.Pub. 131540.29B3-3044.29Definition of Emergency and Urgent Care Situations1540.30B3-3044.30Denial of Payment to Employers of Opt-Out Physicians andPractitioners1540.31B3-3044.31Denial of Payment to Beneficiaries and Others1540.32B3-3044.32Payment for Medically Necessary Services Ordered or Prescribedby an Opt-Out Physician or Practitioner1540.33B3-3044.33Mandatory Claims Submission1540.34B3-3044.34Renewal of Opt-Out1540.35B3-3044.35Early Termination of plication to Medicare Choice Contracts1540.38B3-3044.38Claims Denial Notices to Opt-Out Physicians and Practitioners1540.39B3-3044.39Claims Denial Notices to 550.21550.3B3-2049.3Incident-to Requirements1550.4B3-2049.4Reasonableness and NecessityA3-3112.4BCarrierPub. s and BiologicalsDefinition of Drug or BiologicalAB-02-072,AB-02-139Determining Self-Administration of Drug or Biological
NewChap.NewSect.Int.Pub. 131550.4.1B3-2049.4Approved Use of Drug1550.4.2B3-2049.3Unlabeled Use of Drug1550.4.3B3-2049.4Examples of Not Reasonable and Necessary1550.4.4B3-2049.4Payment for Antigens and 1550.4.5B3-2049.4CUnlabeled Use For Anti-Cancer Drugs1550.4.6B3-2049.4C5Less Than Effective Drug1550.4.7B3-2049.4C6Denial of Medicare Payment for Compounded Drugs Produced inViolation of Federal Food, Drug, and Cosmetic Act1550.5B3-2049.5Self-Administered Drugs and A,A3-3157A1CarrierPub. 2049.5Immunosuppressive ents for Medicare Coverage for EPOMedicare Coverage of Epoetin Alfa (Procrit) for Preoperative 30.4B3AB-99-59A3-3112.4B5DescriptionOral Anti-Cancer DrugsOral Anti-Nausea (Anti-Emetic) DrugsHO-230.4B.2Hemophilia Clotting Factors
NewChap.NewSect.Int.Pub. 13CarrierPub. 14PMs1560B3-2050Services and Supplies1560.1B3-2050.1Incident to Physician’s Professional Services1560.2B3-2050.2Services of Nonphysician Personnel Furnished Incident toPhysician’s Services1560.3B3-2050.3Incident to Physician’s Service in Clinic1560.4B3-205lServices Incident to a Physician’s Service to Homebound PatientsUnder General Physician Supervision1560.4.1B3-2051.1Definition of Homebound Patient Under the Medicare HomeHealth (HH) Benefit1570B3-2055Sleep Disorder Clinics1580B3-2070Requirements for Diagnostic X-Ray, Diagnostic Laboratory,and Other Diagnostic Tests1580.1B3-2070.1Clinical Laboratory Services1580.1.1B3-2070.1ECertification Changes1580.1.2B3-2070.1FCarrier Contacts With Independent Clinical Laboratories1580.1.3B3-2070.1GIndependent Laboratory Service to a Patient in the Patient’sHome or an Institution1580.2B3-2070.2Psychological Tests1580.3B3-2070.3PM-B-01-34,B-02-004,pm AB-02-080OtherDescriptionOtologic Evaluations
NewChap.NewSect.Int.Pub. 13CarrierPub. 14PMsOtherDescription1580.3.1B3-2070.3Definition of Qualified Audiologist1580.4B3-2070.4Coverage of Portable X-Ray Services Not Under the DirectSupervision of a Physician1580.4.1B3-2070.4ADiagnostic X-Ray Tests1580.4.2B3-2070.4BApplicability of Health and Safety Standards1580.4.3B3-2070.4CScope of Portable X-Ray Benefit1580.4.4B3-2070.4DExclusions From Coverage as Portable X-Ray X-Ray, Radium, and Radioactive Isotope Therapy15100A3-3110.3B3-2079HO-228.3Surgical Dressings, Splints, Casts, and Other Devices Used forReductions of Fractures and le Medical Equipment - HHA-220.2,HO-235.6,HHA-220.3Definition of Durable Medical Equipment15110.2A3-3113.3 A3-3113.3DB3-2100.4HO-235.3 235DHHA-220.4Repairs, Maintenance, Replacement, and Delivery
NewChap.NewSect.Int.Pub. 13CarrierPub. 100.5HO-235.4,HHA-220.5Coverage of Supplies and cellaneous Issues Included in the Coverage of Equipment110.5A3-3113.7BB3-3011HO-235.7BIncurred Expense Dates for Durable Medical Equipment15110.6A3-3113.7DHO-235.7CDetermining Months for Which Periodic Payments May be Madefor Equipment Used in an c Shoes for Individuals with Diabetes15150B3-2136Dental Services15150.115160B3-2150Clinical Psychologist Services15170B3-2152Clinical Social Worker Services15180B3-2154Nurse-midwife Services15190B3-2156Physician Assistant (PA) Services15200B3-2158Nurse Practitioner (NP) ServicesNo Payment for Purchased Equipment Delivered Outside theUnited States or Before Beneficiary’s Coverage BeganAB-01-06HO-228.4,HO-229Prosthetic DevicesHO-228.5Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs,Arms, and EyesPASS memoRead.014Dental Splints Used for the Treatment of TemporomandibularJoint (TMJ) Syndrome
NewChap.NewSect.Int.Pub. 13CarrierPub. 14PMsOther1521015220A3-3147B3-2200HO-241.1Coverage of Provider Outpatient Physical Therapy, OccupationalTherapy, and Speech Pathology Services under rapy Services Furnished Under Arrangements with Providersand s for Coverage of Outpatient Physical Therapy,Occupational Therapy, or Speech Pathology 1HO-242.1Physician’s Certification and Outpatient Must be Under Care of ient Physical Therapy, Occupational Therapy, or SpeechPathology Services Furnished Under Plan15220.3.4A3-3148.4B3-2206.4HO-242.4Requirement That Services Be Furnished on an Outpatient Basis15230B3-2210 2210.3Payable Physical Therapy15230.1B3-2215Services Furnished by a Physical or Occupational Therapistin Private Practice15230.215230.3B3-2160Clinical Nurse Specialist (CNS) ServicesB3-2218A3-3149Physical Therapy and Occupational Therapy Provided byPhysicians and Physician EmployeesHO-242.5B3-2216DescriptionPhysical Therapy in Private PracticeCovered Speech-Language Pathology Services
NewChap.NewSect.Int.Pub. 13CarrierPub. -4118Chiropractic Services - General15240.1B3-2251Coverage of Chiropractic Services15240.1.1B3-2251.1Manual Manipulation15240.1.2B3-2251.2Subluxation May be Demonstrated by X-Ray or Physician’sExam15240.1.3B3-2251.3Necessity for 51.5Treatment Parameters15250B3-2255Medical and Other Health Services Furnished to Inpatients ofHospitals and Skilled Nursing Facilities15260B3-2265Ambulatory Surgical Center Services15260.1B3-2265.1Definition of Ambulatory Surgical Center15260.2B3-2265.2Ambulatory Surgical Center Services15260.3B3-2265.3Services Furnished in ASCs Which are Not ASC Facility Services15260.4B3-2265.4Coverage of Services in ASCs Which are Not ASC Services15260.5B3-2266List of Covered Ambulatory Surgical Center ProceduresCovered Occupational TherapyB3-2217AB-02-156Coverage for Neuromuscular Electrical Stimulation(NMES)
NewChap.NewSect.Int.Pub. 13CarrierPub. 14PMsOther15260.5.1B3-2266.1Nature and Applicability of ASC List15260.5.2B3-2266.2Nomenclature and Organization of the List15260.5.3B3-2266.3Rebundling of CPT Codes15270B3-15516C15270.1CMSEligibility Criteria15270.2CMSList of Medicare Telehealth Services15270.3CMSConditions of Payment15270.4CMSPayment – Physician/Practitioner at a Distant Site15270.5CMSOriginating Site Facility Fee Payment vered Services and HCPCS Codes15280.2.2B3-4180.2Coverage CriteriaAB-01-69,AB-02-052,AB 02-053DescriptionTelehealth ServicesPreventive and Screening Services(Section heading only with references to other CMSmanuals)A-01-13,A-01-105B3 41844184.9B-01-46Glaucoma ScreeningColorectal Cancer Screening(Section heading only)
NewChap.NewSect.Int.Pub. 13CarrierPub. 14PMsOther15280.2.3B3-4180.3Determining Whether or Not the Beneficiary is at High Riskfor Developing Colorectal Cancer15280.2.4B3-4180.4Determining Frequency Standards15280.2.5B3-4180.5Noncovered Services15280.3A3-3660.10B3-4601.1Screening Mammography15280.4A3-3628.1B3-4603.1Screening Pap Smears15290A3-3158B3-2323,B3-4120.115300AB 02-151,B-01-40Diabetes Outpatient Self-Management Training Services15300.1AB 02-151,B-01-40Coverage Requirements15300.2AB 02-151,B-01-40Certified Providers15300.3AB 02-151,B-01-40Frequency of Training15300.4AB 02-151,B-01-40Outpatient Diabetes Self-Management Training15300.5AB 02-151,B-01-40Bill Processing RequirementsHO-260.9DescriptionFoot Care
Medicare Benefit Policy Manual Chapter 15 - Medical and Other Health Services Crosswalk New Chap. New Sect. Int. Pub. 13 Carrier Pub. 14 PMs OtherDescription 1510 B3-2000 HO-245 Supplementary Medical Insurance (Part B) Provisions 1520 B3-2005 When Part B Expenses Are Incurred 1520.1B3-2005.l Physicians' Expense for Surgery, Childbirth, and .
