Page 184 - Medicare Benefit Policy Manual

For example, if a patient is treated and the provider/supplier cannot produce (on
contractor request) a plan of care (timely or delayed) for the billed treatment dates
certified by a physician/NPP, then that service might be denied for lack of the required
certification. If an appropriate certification is later produced, the denial shall be
overturned.

In the case of a service furnished under a provider agreement as described in
42CFR489.21, the provider is precluded from charging the beneficiary for services
denied as a result of missing certification.

However, if the service is provided by a supplier (in the office of the physician/NPP, or
therapist) a technical denial due to absence of a certification results in beneficiary
liability. For that reason, it is recommended that the patient be made aware of the need
for certification and the consequences of its absence.

A technical denial decision may be reopened by the contractor or reversed on appeal as
appropriate, if delayed certification is later produced.

220.1.4 - Requirement That Services Be Furnished on an Outpatient
Basis
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)

Reference: 42CFR410.60

Therapy services are payable under the Physician Fee Schedule when furnished by 1.) a
provider to its outpatients in the patient’s home; 2.) a provider to patients who come to
the facility’s outpatient department; 3.) a provider to inpatients of other institutions, or
4.) a supplier to patients in the office or in the patient’s home. (CORF rules differ on
providing therapy at home.)

Coverage includes therapy services furnished by participating hospitals and SNFs to their
inpatients who have exhausted Part A inpatient benefits or who are otherwise not eligible
for Part A benefits. Providers of therapy services that have inpatient facilities, other than
participating hospitals and SNFs, may not furnish covered therapy services to their own
inpatients. However, since the inpatients of one institution may be considered the
outpatients of another institution, all providers of therapy services may furnish such
services to inpatients of another health facility.

A certified distinct part of an institution is considered to be a separate institution from a
nonparticipating part of the institution. Consequently, the certified distinct part may
render covered therapy services to the inpatients of the noncertified part of the institution
or to outpatients. The certified part must bill the A/B MAC (A) under Part B.