CMS Pub. 100-02, ch. 15, § 60.4

Physician Supervision

(Rev. 1, 10-01-03)

B3-2051

A. When Covered

In some medically underserved areas there are only a few physicians available to provide services over

broad geographic areas or to a large patient population. The lack of medical personnel (and, in many

instances, a home health agency servicing the area) significantly reduces the availability of certain medical

services to homebound patients. Some physicians and physician-directed clinics, therefore, call upon nurses

and other paramedical personnel to provide these services under general (rather than direct) supervision. In

some areas, such practice has tended to become the accepted method of delivery of these services.

The Senate Finance Committee Report accompanying the 1972 Amendments to the Act recommended that

the direct supervision requirement of the “incident to” provision be modified to provide coverage for

services provided in this manner.

Accordingly, to permit coverage of certain of these services, the direct supervision criterion in §60.2 above

is not applicable to individual or intermittent services outlined in this section when they are performed by

personnel meeting any pertinent State requirements (e.g., a nurse, technician, or physician extender) and

where the criteria listed below also are met:

1 The patient is homebound; i.e., confined to his or her home (see §60.4.1 for the definition of a

“homebound” patient and §110.1 (D) for the definition of patient’s “place of residence.”

2 The service is an integral part of the physician’s service to the patient (the patient must be one the

physician is treating), and is performed under general physician supervision by employees of the

physician or clinic. General supervision means that the physician need not be physically present at

the patient’s place of residence when the service is performed; however, the service must be

performed under his or her overall supervision and control.

The physician orders the service(s) to be performed, and contact is maintained between the nurse or

other employee and the physician, e.g., the employee contacts the physician directly if additional

instructions are needed, and the physician must retain professional responsibility for the service. All

other “incident to” requirements must be met (see §§60-60.4).

3 The services are included in the physician’s/clinic’s bill, and the physician or clinic has incurred an

expense for them (see §60.2).

4 The services of the paramedical are required for the patient’s care; that is, they are reasonable and

necessary as defined in the Medicare Benefit Policy Manual, Chapter 16, “General Exclusions from

Coverage,” §20.

5 When the service can be furnished by an HHA in the local area, it cannot be covered when furnished

by a physician/clinic to a homebound patient under this provision, except as described in §60.4.C.

B. Covered Services

Where the requirements in §60.4.A are met, the direct supervision requirement in §60.2 is not applicable to

the following services:

1. Injections;

2. Venipuncture;

3. EKGs;

4. Therapeutic exercises;

5. Insertion and sterile irrigation of a catheter;

6. Changing of catheters and collection of catheterized specimen for urinalysis and culture;

7. Dressing changes, e.g., the most common chronic conditions that may need dressing changes are

decubitus care and gangrene;

8. Replacement and/or insertion of nasogastric tubes;

9. Removal of fecal impaction, including enemas;

10. Sputum collection for gram stain and culture, and possible acid-fast and/or fungal stain and culture;

11. Paraffin bath therapy for hands and/or feet in rheumatoid arthritis or osteoarthritis;

12. Teaching and training the patient for:

a. The care of colostomy and ileostomy;

b. The care of permanent tracheostomy;

c. Testing urine and care of the feet (diabetic patients only); and

d. Blood pressure monitoring.

Teaching and training services (also referred to as educational services) can be covered only where they

provide knowledge essential for the chronically ill patient’s participation in his or her own treatment and

only where they can be reasonably related to such treatment or diagnosis. Educational services that provide

more elaborate instruction than is necessary to achieve the required level of patient education are not

covered. After essential information has been provided, the patient should be relied upon to obtain

additional information on his or her own.

C. Relation to Home Health Benefits

This coverage should not be considered as an alternative to home health benefits where there is a

participating home health agency in the area which could provide the needed services on a timely basis. For

example, two of the three services initially included under this coverage - injections and venipuncture - are

skilled nursing services that could be covered as home health services (EKG is not a covered Home Health

Agency (HHA) service) if the patient is eligible for home health benefits and there is a home health agency

available. Thus, postpayment review of these claims will include measures to assure that physicians and

clinics do not provide a substantial number of services under this coverage when they could otherwise have

been performed by a home health agency.

In these circumstances, the physician or clinic is expected to assist the patient in obtaining such skilled

services together with the other home health services (such as aide services). However, HHA services are

not considered available where the HHA cannot respond on a timely basis or where the physician could not

have foreseen that intermittent services would be needed.

Refer to the Medicare Claims Processing Manual, Chapter 10, “Home Health Agency Billing,” for a more in

depth discussion of home health services.