Page 11 - Medicare Benefit Policy Manual

insurance (SMI) but receives the item after the effective date of SMI enrollment, the
expense is considered incurred after entitlement began. However, if an item not custom-
made for the beneficiary was ordered but not furnished, no reimbursement can be made.
(See §20.3 for rules concerning custom-made items ordered but not furnished and the
Medicare Claims Processing Manual, Chapter 20, “Durable Medical Equipment,
Prosthetics and Orthotics, and Supplies (DMEPOS),” for additional rules concerning the
date of incurred expenses for durable medical equipment.)

20.1 - Physician Expense for Surgery, Childbirth, and Treatment for
Infertility
(Rev. 1, 10-01-03)
B3-2005.l

A. Surgery and Childbirth

Skilled medical management is covered throughout the events of pregnancy, beginning
with diagnosis, continuing through delivery and ending after the necessary postnatal care.
Similarly, in the event of termination of pregnancy, regardless of whether terminated
spontaneously or for therapeutic reasons (i.e., where the life of the mother would be
endangered if the fetus were brought to term), the need for skilled medical management
and/or medical services is equally important as in those cases carried to full term. After
the infant is delivered and is a separate individual, items and services furnished to the
infant are not covered on the basis of the mother’s eligibility.

Most surgeons and obstetricians bill patients an all-inclusive package charge intended to
cover all services associated with the surgical procedure or delivery of the child. All
expenses for surgical and obstetrical care, including preoperative/prenatal examinations
and tests and post-operative/postnatal services, are considered incurred on the date of
surgery or delivery, as appropriate. This policy applies whether the physician bills on a
package charge basis, or itemizes the bill separately for these items.

Occasionally, a physician’s bill may include charges for additional services not directly
related to the surgical procedure or the delivery. Such charges are considered incurred on
the date the additional services are furnished.

The above policy applies only where the charges are imposed by one physician or by a
clinic on behalf of a group of physicians. Where more than one physician imposes
charges for surgical or obstetrical services, all preoperative/prenatal and post-
operative/postnatal services performed by the physician who performed the surgery or
delivery are considered incurred on the date of the surgery or delivery. Expenses for
services rendered by other physicians are considered incurred on the date they were
performed.

B. Treatment for Infertility