Page 13 - Medicare Benefit Policy Manual

Where a supplier breaches an agreement to make a prosthesis, brace, or other custom-
made device for a Medicare beneficiary, e.g., an unexcused failure to provide the article
within the time specified in the contract, payment may not be made for any work or
material expended on the item. Whether a particular supplier has lived up to its
agreement, of course, depends on the facts in the individual case.

30 - Physician Services
(Rev. 10639; Issued: 03-12-2021; Effective: 01-01-2021; Implementation: 04-12-
2021)

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