CMS Pub. 100-02, ch. 15, § 30

A. General

Physician services are the professional services performed by a physician or physicians for a patient

including diagnosis, therapy, surgery, consultation, and care plan oversight.

The physician must render the service for the service to be covered. (See Pub. 100-01, Medicare General

Information, Eligibility, and Entitlement Manual, Chapter 5, §70, for definition of physician.) A service

may be considered to be a physician’s service where the physician either examines the patient in person or is

able to visualize some aspect of the patient’s condition without the interposition of a third person’s

judgment. Direct visualization would be possible by means of x-rays, electrocardiogram and

electroencephalogram tapes, tissue samples, etc.

For example, the interpretation by a physician of an actual electrocardiogram or electroencephalogram

reading that has been transmitted via telephone (i.e., electronically rather than by means of a verbal

description) is a covered service.

Professional services of the physician are covered if provided within the United States, and may be

performed in a home, office, institution, or at the scene of an accident. A patient’s home, for this purpose, is

anywhere the patient makes his or her residence, e.g., home for the aged, a nursing home, a relative’s home.

B. Consultations

As of January 1, 2010, CMS no longer recognizes consultation codes for Medicare payment, except for

inpatient telehealth consultation HCPCS G-codes. Instead, physicians and qualified nonphysician

practitioners are instructed to bill a new or established patient office/outpatient visit CPT code or appropriate

hospital or nursing facility care code. For further detail regarding reporting services that would otherwise be

described by the CPT consultation codes (99241-99245 and 99251-99255), see Pub. 100-04, Medicare

Claims Processing Manual, chapter 12, section 30.6. For detailed instructions regarding reporting telehealth

consultation services and other telehealth services, see Pub. 100-04, chapter 12, section 190.3.

C. Patient-Initiated Second Opinions

Patient-initiated second opinions that relate to the medical need for surgery or for major nonsurgical

diagnostic and therapeutic procedures (e.g., invasive diagnostic techniques such as cardiac catheterization

and gastroscopy) are covered under Medicare. In the event that the recommendation of the first and second

physician differs regarding the need for surgery (or other major procedure), a third opinion is also covered.

Second and third opinions are covered even though the surgery or other procedure, if performed, is

determined not covered. Payment may be made for the history and examination of the patient, and for other

covered diagnostic services required to properly evaluate the patient’s need for a procedure and to render a

professional opinion. In some cases, the results of tests done by the first physician may be available to the

second physician.

D. Concurrent Care

Concurrent care exists where more than one physician renders services more extensive than consultative

services during a period of time. The reasonable and necessary services of each physician rendering

concurrent care could be covered where each is required to play an active role in the patient’s treatment, for

example, because of the existence of more than one medical condition requiring diverse specialized medical

services.

In order to determine whether concurrent physicians’ services are reasonable and necessary, the A/B MAC

(B) must decide the following:

1. Whether the patient’s condition warrants the services of more than one physician on an attending

(rather than consultative) basis, and

2. Whether the individual services provided by each physician are reasonable and necessary.

In resolving the first question, the A/B MAC (B) should consider the specialties of the physicians as well as

the patient’s diagnosis, as concurrent care is usually (although not always) initiated because of the existence

of more than one medical condition requiring diverse specialized medical or surgical services. The

specialties of the physicians are an indication of the necessity for concurrent services, but the patient’s

condition and the inherent reasonableness and necessity of the services, as determined by the A/B MAC

(B)’s medical staff in accordance with locality norms, must also be considered. For example, although

cardiology is a sub-specialty of internal medicine, the treatment of both diabetes and of a serious heart

condition might require the concurrent services of two physicians, each practicing in internal medicine but

specializing in different sub-specialties.

While it would not be highly unusual for concurrent care performed by physicians in different specialties

(e.g., a surgeon and an internist) or by physicians in different subspecialties of the same specialty (e.g., an

allergist and a cardiologist) to be found medically necessary, the need for such care by physicians in the

same specialty or subspecialty (e.g., two internists or two cardiologists) would occur infrequently since in

most cases both physicians would possess the skills and knowledge necessary to treat the patient. However,

circumstances could arise which would necessitate such care. For example, a patient may require the

services of two physicians in the same specialty or sub-specialty when one physician has further limited his

or her practice to some unusual aspect of that specialty, e.g., tropical medicine. Similarly, concurrent

services provided by a family physician and an internist may or may not be found to be reasonable and

necessary, depending on the circumstances of the specific case. If it is determined that the services of one of

the physicians are not warranted by the patient’s condition, payment may be made only for the other

physician’s (or physicians’) services.

Once it is determined that the patient requires the active services of more than one physician, the individual

services must be examined for medical necessity, just as where a single physician provides the care. For

example, even if it is determined that the patient requires the concurrent services of both a cardiologist and a

surgeon, payment may not be made for any services rendered by either physician which, for that condition,

exceed normal frequency or duration unless there are special circumstances requiring the additional care.

The A/B MAC (B) must also assure that the services of one physician do not duplicate those provided by

another, e.g., where the family physician visits during the post-operative period primarily as a courtesy to

the patient.

Hospital admission services performed by two physicians for the same beneficiary on the same day could

represent reasonable and necessary services, provided, as stated above, that the patient’s condition

necessitates treatment by both physicians. The level of difficulty of the service provided may vary between

the physicians, depending on the severity of the complaint each one is treating and that physician’s prior

contact with the patient. For example, the admission services performed by a physician who has been

treating a patient over a period of time for a chronic condition would not be as involved as the services

performed by a physician who has had no prior contact with the patient and who has been called in to

diagnose and treat a major acute condition.

A/B MACs (B) should have sufficient means for identifying concurrent care situations. A correct coverage

determination can be made on a concurrent care case only where the claim is sufficiently documented for the

A/B MAC (B) to determine the role each physician played in the patient’s care (i.e., the condition or

conditions for which the physician treated the patient). If, in any case, the role of each physician involved is

not clear, the A/B MAC (B) should request clarification.

E. Completion of Claims Forms

Separate charges for the services of a physician in completing a Form CMS-1500, a statement in lieu of a

Form CMS-1500, or an itemized bill are not covered. Payment for completion of the Form CMS-1500

claim form is considered included in the fee schedule amount.

F. Care Plan Oversight Services

Care plan oversight is supervision of patients under care of home health agencies or hospices that require

complex and multidisciplinary care modalities involving regular physician development and/or revision of

care plans, review of subsequent reports of patient status, review of laboratory and other studies,

communication with other health professionals not employed in the same practice who are involved in the

patient’s care, integration of new information into the care plan, and/or adjustment of medical therapy.

Such services are covered for home health and hospice patients, but are not covered for patients of skilled

nursing facilities (SNFs), nursing home facilities, or hospitals.

These services are covered only if all the following requirements are met:

1. The beneficiary must require complex or multi-disciplinary care modalities requiring ongoing

physician involvement in the patient’s plan of care;

2. The care plan oversight (CPO) services should be furnished during the period in which the

beneficiary was receiving Medicare covered HHA or hospice services;

3. The physician who bills CPO must be the same physician who signed the home health or hospice

plan of care;

4. The physician furnished at least 30 minutes of care plan oversight within the calendar month for

which payment is claimed. Time spent by a physician’s nurse or the time spent consulting with

one’s nurse is not countable toward the 30-minute threshold. Low-intensity services included as part

of other evaluation and management services are not included as part of the 30 minutes required for

coverage;

5. The work included in hospital discharge day management (codes 99238-99239) and discharge from

observation (code 99217) is not countable toward the 30 minutes per month required for work on the

same day as discharge but only for those services separately documented as occurring after the

patient is actually physically discharged from the hospital;

6. The physician provided a covered physician service that required a face-to-face encounter with the

beneficiary within the 6 months immediately preceding the first care plan oversight service. Only

evaluation and management services are acceptable prerequisite face-to-face encounters for CPO.

EKG, lab, and surgical services are not sufficient face-to-face services for CPO;

7. The care plan oversight billed by the physician was not routine post-operative care provided in the

global surgical period of a surgical procedure billed by the physician;

8. If the beneficiary is receiving home health agency services, the physician did not have a significant

financial or contractual interest in the home health agency. A physician who is an employee of a

hospice, including a volunteer medical director, should not bill CPO services. Payment for the

services of a physician employed by the hospice is included in the payment to the hospice;

9. The physician who bills the care plan oversight services is the physician who furnished them;

10. Services provided incident to a physician’s service do not qualify as CPO and do not count toward

the 30-minute requirement;

11. The physician is not billing for the Medicare end stage renal disease (ESRD) capitation payment for

the same beneficiary during the same month; and

12. The physician billing for CPO must document in the patient’s record the services furnished and the

date and length of time associated with those services.

G. Medical Record Documentation for Part B Services

This medical record documentation requirement applies to Part B professional services that are paid under

the Medicare physician fee schedule. Accordingly, for Part B covered services, the certified nurse-midwife,

nurse practitioner, physician assistant, clinical nurse specialist, and any individual who is authorized under

Medicare law to furnish and bill for their professional services, whether or not they are acting in a teaching

role, may review and verify (sign and date), rather than re-document notes in a patient’s medical record

made by physicians, residents, nurses, and students (including students in therapy or other clinical

disciplines), or other members of the medical team, including as applicable, notes documenting the

physician or nonphysician practitioner’s presence and participation in the service.

For documentation requirements specific to E/M services furnished by physicians and certain nonphysician

practitioners, see Chapter 12, section 30.6 of the Medicare Claims Processing Manual, publication 100-04.