Physician’s Services and Other Professional Services Excluded

20.1.1 - Physician’s Services and Other Professional Services Excluded From Part A PPS Payment and the Consolidated Billing Requirement (Rev. 12283, Issued:10-05-23, Effective:01-08-24, Implementation:01-08-24) Except for the therapy services (see §20.5), physician’s professional services and services of certain nonphysician providers listed below are excluded from Part A PPS payment and the requirement for consolidated billing, and must be billed separately by the practitioner to the A/B MAC (B). See below for Rural Health Clinic (RHC)/Federally Qualified Health Center (FQHC) instructions. For this purpose “physician service” means the professional services of the physician as defined under the Medicare physician Fee Schedule. For services that contain both a technical component and a professional component, the technical component, if any, must be billed by the SNF for its Part A inpatients. The A/B MAC (B) will pay only the professional component to the physician. For example, the technical component of a diagnostic radiology test (representing the performance of the procedure itself) is subject to SNF CB, whereas the professional component (representing the physician’s interpretation of the test results) is excluded and, thus, remains separately billable under Part B. • Physician’s services other than physical, occupational, and speech language pathology services furnished to SNF residents; • Physician assistants, working under a physician’s supervision; • Nurse practitioners and clinical nurse specialists working in collaboration with a physician; • Certified nurse-midwives; • Qualified psychologists; • Marriage and family therapists; • Mental health counselors; and • Certified registered nurse anesthetists. SNF CB excludes the categories of practitioner services described above, and this exclusion applies specifically to those professional services that ordinarily require performance by the practitioner personally (see the regulations at 42 CFR 411.15(p)(2)(i) and 415.102(a)(3)). This means, for example, that an otherwise bundled task (such as a routine blood draw) cannot be converted into an excluded physician service merely by having a physician perform it personally, as such a task does not ordinarily require performance by the physician. This exclusion also does not encompass services that are performed by someone else as an incident to the practitioner’s professional service. Such “incident to” services remain subject to SNF CB and, accordingly, must be billed to Medicare by the SNF itself (see §10.3). Providers with the following specialty codes assigned by CMS upon enrollment with Medicare are considered physicians for this purpose. Some limitations are imposed by §§1861(q) and (r) of the Act. These providers may bill their A/B MAC (B) directly. Physician Specialty Codes 01 General Practice 02 General Surgery 03 Allergy/Immunology 04 Otolaryngology 05 Anesthesiology 06 Cardiology 07 Dermatology 08 Family Practice 10 Gastroenterology 11 Internal Medicine Physician Specialty Codes 12 Osteopathic Manipulative Therapy 13 Neurology 14 Neurosurgery 16 Obstetrics Gynecology 18 Ophthalmology 19 Oral Surgery (Dentists only) 20 Orthopedic Surgery 22 Pathology 24 Plastic and Reconstructive Surgery 25 Physical Medicine and Rehabilitation 26 Psychiatry 28 Colorectal Surgery (formerly Proctology) 29 Pulmonary Disease 30 Diagnostic Radiology 33 Thoracic Surgery 34 Urology 35 Chiropractic 36 Nuclear Medicine 37 Pediatric Medicine 38 Geriatric Medicine 39 Nephrology 40 Hand Surgery 41 Optometry 44 Infectious Disease 46 Endocrinology 48 Podiatry 66 Rheumatology 69 Independent Labs 70 Multi specialty Clinic or Group Practice 76 Peripheral Vascular Disease 77 Vascular Surgery 78 Cardiac Surgery 79 Addiction Medicine 81 Critical Care (Intensivists) 82 Hematology 83 Hematology/Oncology 84 Preventive Medicine 85 Maxillofacial Surgery 86 Neuropsychiatry 90 Medical Oncology 91 Surgical Oncology 92 Radiation Oncology 93 Emergency Medicine 94 Interventional Radiology 98 Gynecological/Oncology Nonphysician Provider Specialty Codes 99 Unknown Physician Specialty 42 Certified Nurse Midwife 43 Certified Registered Nurse Anesthetist, Anesthesia Assistants (effective 1/1/89) 50 Nurse Practitioner 62 Clinical Psychologist (billing independently) 68 Clinical Psychologist 89 Certified Clinical Nurse Specialist 97 Physician Assistant NOTE: Some HCPCS codes are defined as all professional components in the fee schedule. Fee schedule definitions apply for this purpose. Effective July 1, 2001, the Benefits Improvement and Protection Act (BIPA) established payment method II, in which CAHs can bill and be paid for physician services billed to their A/B MAC (A). CAHs must bill the professional fees using revenue codes 96x, 97x, or 98x on an 85x type of bill (TOB). Like professional services billed to the A/B MAC (B), the specific line items containing these revenue codes for professional services are excluded from the requirement for consolidated billing. RHC/FQHC Instructions: Effective January 1, 2005, section 410 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) amended the SNF consolidated billing law to specify that when a SNF’s Part A resident receives the services of a physician (or another type of practitioner that the law identifies as being excluded from SNF consolidated billing) from a RHC or a FQHC, those services are not subject to CB merely by virtue of being furnished under the auspices of the RHC or FQHC. Accordingly, under section 410 of the MMA, services otherwise included within the scope of RHC and FQHC services that are also described in clause (ii) of section 1888(e)(2)(A) are excluded from consolidated billing, effective with services furnished on or after January 1, 2005. Only this subset of RHC/FQHC services may be covered and paid separately when furnished to SNF residents during a covered Part A stay (see the regulations at 42 CFR 411.15(p)(2)(xvii) and 405.2411(b)(2)). Use TOBs 71x and 73x, respectively, to bill for these RHC/FQHC services. See Pub. 100-02, Medicare Benefit Policy Manual, chapter 13 for additional information on Part B coverage of RHC/FQHC services.