100-02 Medicare Benefit Policy Manual: Chapter 15 Crosswalk

Medicare Benefit Policy Manual
Chapter 15 - Medical and Other Health Services
Crosswalk
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PMs 	Other 	Description
15 	10 	B3-2000 	HO-245 	Supplementary Medical Insurance (Part B) Provisions
15 	20 	B3-2005 	When Part B Expenses Are Incurred
15 	20.1 	B3-2005.l 	Physicians’ Expense for Surgery, Childbirth, and Treatment for
Infertility
15 	20.2 	B3-2005.2,
B3-4145
Physicians’ Expense for Allergy Treatment
15 	20.3 	B3-2005.3 	Artificial Limbs, Braces, and Other Custom Made Items Ordered
But Not Furnished
15 	30 	B3-2020,
B3-4142,
B3-15513
Physicians’ Services
15 	30.1 	A3-3145 	B3-2020.6,
B3-8000-8099
Provider-Based Physician Services
15 	30.2 	B3-2020.7,
B3-8210,
B3-15016
Teaching Physician Services
15 	30.3 	A3-3115 	B3-2020.8 	Interns and Residents
15 	30.4 	B3-2020.25 	Optometrist’s Services

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PMs 	Other 	Description
15 	30.5 	B3-2020.26 	Chiropractor’s Services
15 	30.6 	AB-02-150 	Indian Health Service (IHS) Physician and Nonphysician
Services
15 	40 	B3-3044 	B-97-17 	Effect of Beneficiary Agreements Not To Use Medicare
Coverage
15 	40.1 	B3-3044.1 	Private Contracts Between Beneficiaries and
Physicians/Practitioners
15 	40.2 	B3-3044.2 	General Rules of Private Contracts
15 	40.3 	B3-3044.3 	Effective Date of the Opt-Out Provision
15 	40.4 	B3-3044.4 	Definition of Physician/Practitioner
15 	40.5 	B3-3044.5 	When a Physician or Practitioner Opts Out of Medicare
15 	40.6 	B3-3044.6 	When Payment May be Made to a Beneficiary for Service of an
Opt-Out Physician/Practitioner
15 	40.7 	B3-3044.7 	Definition of a Private Contract
15 	40.8 	B3-3044.8 	Requirements of a Private Contract
15 	40.9 	B3-3044.9 	Requirements of the Opt-Out Affidavit
15 	40.10 	B3-3044.10 	Failure to Properly Opt Out
15 	40.11 	B3-3044.11 	Failure to Maintain Opt-Out
15 	40.12 	B3-3044.12 	Actions to Take in Cases of Failure to Maintain Opt-Out
15 	40.13 	B3-3044.13 	Physician/Practitioner Who Has Never Enrolled in Medicare

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PMs 	Other 	Description
15 	40.14 	B3-3044.14 	Non-Participating Physicians or Practitioners Who Opt Out of
Medicare
15 	40.15 	B3-3044.15 	Excluded Physicians and Practitioners
15 	40.16 	B3-3044.16 	Relationship Between Opt-Out and Medicare Participation
Agreements
15 	40.17 	B3-3044.17 	Participating Physicians and Practitioners
15 	40.18 	B3-3044.18 	Physicians or Practitioners Who Choose to Opt Out of Medicare
15 	40.19 	B3-3044.19 	Relationship to Noncovered Services
15 	40.20 	B3-3044.20 	Maintaining Information on Opt-Out Physicians
15 	40.21 	B3-3044.21 	Informing Managed Care Plans of the Identity of the Opt-Out
Physicians or Practitioners
15 	40.22 	B3-3044.22 	Informing the National Supplier Clearinghouse (NSC) of the
Identity of the Opt-Out Physicians or Practitioners
15 	40.23 	B3-3044.23 	Organizations That Furnish Physician or Practitioner Services
15 	40.24 	B3-3044.24 	The Difference Between Advance Beneficiary Notices (ABN)
and Private Contracts
15 	40.25 	B3-3044.25 	Private Contracting Rules When Medicare is the Secondary Payer
15 	40.26 	B3-3044.26 	Registration and Identification of Physicians or Practitioners Who
Opt Out
15 	40.27 	B3-3044.27 	System Identification
15 	40.28 	B3-3044.28 	Emergency and Urgent Care Situations

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PMs 	Other 	Description
15 	40.29 	B3-3044.29 	Definition of Emergency and Urgent Care Situations
15 	40.30 	B3-3044.30 	Denial of Payment to Employers of Opt-Out Physicians and
Practitioners
15 	40.31 	B3-3044.31 	Denial of Payment to Beneficiaries and Others
15 	40.32 	B3-3044.32 	Payment for Medically Necessary Services Ordered or Prescribed
by an Opt-Out Physician or Practitioner
15 	40.33 	B3-3044.33 	Mandatory Claims Submission
15 	40.34 	B3-3044.34 	Renewal of Opt-Out
15 	40.35 	B3-3044.35 	Early Termination of Opt-Out
15 	40.36 	B3-3044.36 	Appeals
15 	40.37 	B3-3044.37 	Application to Medicare+Choice Contracts
15 	40.38 	B3-3044.38 	Claims Denial Notices to Opt-Out Physicians and Practitioners
15 	40.39 	B3-3044.39 	Claims Denial Notices to Beneficiaries
15 	40.40 	B3-3044.40 	Reporting
15 	50 	A3-3112.4B 	B3-2049 	HO-230.4B 	Drugs and Biologicals
15 	50.1 	B3-2049.1 	Definition of Drug or Biological
15 	50.2 	AB-02-072,
AB-02-139
Determining Self-Administration of Drug or Biological
15 	50.3 	B3-2049.3 	Incident-to Requirements
15 	50.4 	B3-2049.4 	Reasonableness and Necessity

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PMs 	Other 	Description
15 	50.4.1 	B3-2049.4 	Approved Use of Drug
15 	50.4.2 	B3-2049.3 	Unlabeled Use of Drug
15 	50.4.3 	B3-2049.4 	Examples of Not Reasonable and Necessary
15 	50.4.4 	B3-2049.4 	Payment for Antigens and Immunizations
15 	50.4.4.1 	B3-2049.4 	Antigens
15 	50.4.4.2 	A3-3157A,
A3-3157A1
B3-2049.4 	HO-230.4C
HO-230.4C.1
Immunizations
15 	50.4.5 	B3-2049.4C 	Unlabeled Use For Anti-Cancer Drugs
15 	50.4.6 	B3-2049.4C5 	Less Than Effective Drug
15 	50.4.7 	B3-2049.4C6 	Denial of Medicare Payment for Compounded Drugs Produced in
Violation of Federal Food, Drug, and Cosmetic Act
15 	50.5 	B3-2049.5 	Self-Administered Drugs and Biologicals
15 	50.5.1 	A3-3112.4B3 	AB-01-10 	HO-230.4B3 	Immunosuppressive Drugs
15 	50.5.2 	A3-3112.4B4 	HO-230.4B.4 	Erythropoietin
15 	50.5.2.1 	B3-2049.5 	HO-
230.4B.4.c
Requirements for Medicare Coverage for EPO
15 	50.5.2.2 	AB-99-59 	Medicare Coverage of Epoetin Alfa (Procrit) for Preoperative Use
15 	50.5.3 	A3-3112.4B5 	HO-230.4B.5 	Oral Anti-Cancer Drugs
15 	50.5.4 	AB-97-26 	Oral Anti-Nausea (Anti-Emetic) Drugs
15 	50.5.5 	A3-3112.4B2 	HO-230.4B.2 	Hemophilia Clotting Factors

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PMs 	Other 	Description
15 	60 	B3-2050 	Services and Supplies
15 	60.1 	B3-2050.1 	Incident to Physician’s Professional Services
15 	60.2 	B3-2050.2 	Services of Nonphysician Personnel Furnished Incident to
Physician’s Services
15 	60.3 	B3-2050.3 	Incident to Physician’s Service in Clinic
15 	60.4 	B3-205l 	Services Incident to a Physician’s Service to Homebound Patients
Under General Physician Supervision
15 	60.4.1 	B3-2051.1 	Definition of Homebound Patient Under the Medicare Home
Health (HH) Benefit
15 	70 	B3-2055 	Sleep Disorder Clinics
15 	80 	B3-2070 	Requirements for Diagnostic X-Ray, Diagnostic Laboratory,
and Other Diagnostic Tests
15 	80.1 	B3-2070.1 	Clinical Laboratory Services
15 	80.1.1 	B3-2070.1E 	Certification Changes
15 	80.1.2 	B3-2070.1F 	Carrier Contacts With Independent Clinical Laboratories
15 	80.1.3 	B3-2070.1G 	Independent Laboratory Service to a Patient in the Patient’s
Home or an Institution
15 	80.2 	B3-2070.2 	Psychological Tests
15 	80.3 	B3-2070.3 	PM-B-01-34,
B-02-004,
pm AB-02-080
Otologic Evaluations

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PMs 	Other 	Description
15 	80.3.1 	B3-2070.3 	Definition of Qualified Audiologist
15 	80.4 	B3-2070.4 	Coverage of Portable X-Ray Services Not Under the Direct
Supervision of a Physician
15 	80.4.1 	B3-2070.4A 	Diagnostic X-Ray Tests
15 	80.4.2 	B3-2070.4B 	Applicability of Health and Safety Standards
15 	80.4.3 	B3-2070.4C 	Scope of Portable X-Ray Benefit
15 	80.4.4 	B3-2070.4D 	Exclusions From Coverage as Portable X-Ray Ser
15 	80.4.5 	B3-2070.4F 	Electrocardiograms
15 	90 	B3-2075 	X-Ray, Radium, and Radioactive Isotope Therapy
15 	100 	A3-3110.3 	B3-2079 	HO-228.3 	Surgical Dressings, Splints, Casts, and Other Devices Used for
Reductions of Fractures and Dislocations
15 	110 	A3-3113 	B3-2100 	HO-235,
HHA-220
Durable Medical Equipment - General
15 	110.1 	A3-3113.1,
A3-3113.2,
A3-3113.6
B3-2100.1,
B3-2100.2,
B3-2100.3
HO-235.1,
HHA-220.1,
HO-235.2,
HHA-220.2,
HO-235.6,
HHA-220.3
Definition of Durable Medical Equipment
15 	110.2 	A3-3113.3 -
A3-3113.3D
B3-2100.4 	HO-235.3 -
235D
HHA-220.4
Repairs, Maintenance, Replacement, and Delivery

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15 	110.3 	A3-3113.4 	B3-2100.5 	HO-235.4,
HHA-220.5
Coverage of Supplies and Accessories
15 	110.4 	A3-3113.5 	B3-2100.6 	HO-235.5,
HHA-220.6
Miscellaneous Issues Included in the Coverage of Equipment
15 	110.5 	A3-3113.7B 	B3-3011 	HO-235.7B 	Incurred Expense Dates for Durable Medical Equipment
15 	110.6 	A3-3113.7D 	HO-235.7C 	Determining Months for Which Periodic Payments May be Made
for Equipment Used in an Institution
15 	110.7 	A3-3113.7C 	No Payment for Purchased Equipment Delivered Outside the
United States or Before Beneficiary’s Coverage Began
15 	120 	A3-3110.4,
A3-3111
B3-2130 	HO-228.4,
HO-229
Prosthetic Devices
15 	130 	A3-3110.5 	B3-2133 	AB-01-06 	HO-228.5 	Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs,
Arms, and Eyes
15 	140 	B3-2134 	Therapeutic Shoes for Individuals with Diabetes
15 	150 	B3-2136 	Dental Services
15 	150.1 	PASS memo
Read.014
Dental Splints Used for the Treatment of Temporomandibular
Joint (TMJ) Syndrome
15 	160 	B3-2150 	Clinical Psychologist Services
15 	170 	B3-2152 	Clinical Social Worker Services
15 	180 	B3-2154 	Nurse-midwife Services
15 	190 	B3-2156 	Physician Assistant (PA) Services
15 	200 	B3-2158 	Nurse Practitioner (NP) Services

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15 	210 	B3-2160 	Clinical Nurse Specialist (CNS) Services
15 	220 	A3-3147 	B3-2200 	HO-241.1 	Coverage of Provider Outpatient Physical Therapy, Occupational
Therapy, and Speech Pathology Services under Medical
Insurance
15 	220.1 	A3-3147.1 	B3-2203 	HO-241.1 	Therapy Services Furnished Under Arrangements with Providers
and Clinics
15 	220.2 	B3-2218 	Physical Therapy and Occupational Therapy Provided by
Physicians and Physician Employees
15 	220.3 	A3-3148 	B3-2206 	HO-242 	Conditions for Coverage of Outpatient Physical Therapy,
Occupational Therapy, or Speech Pathology Services
15 	220.3.1 	A3-3148.1.
A3-3322,
A3-3350
B3-2206.1 	HO-242.1 	Physician’s Certification and Recertification
15 	220.3.2 	A3-3148.2 	B3-2206.2 	HO-242.2 	Outpatient Must be Under Care of Physician
15 	220.3.3 	A3-3148.3 	B3-2206.3 	HO-242.3 	Outpatient Physical Therapy, Occupational Therapy, or Speech
Pathology Services Furnished Under Plan
15 	220.3.4 	A3-3148.4 	B3-2206.4 	HO-242.4 	Requirement That Services Be Furnished on an Outpatient Basis
15 	230 	B3-2210 -
2210.3
Payable Physical Therapy
15 	230.1 	B3-2215 	Services Furnished by a Physical or Occupational Therapist
in Private Practice
15 	230.2 	A3-3149 	HO-242.5 	Physical Therapy in Private Practice
15 	230.3 	B3-2216 	Covered Speech-Language Pathology Services

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15 	230.4 	B3-2217 	Covered Occupational Therapy
15 	230.5 	AB-02-156 	Coverage for Neuromuscular Electrical Stimulation
(NMES)
15 	240 	B3-2250,
B3-4118
Chiropractic Services - General
15 	240.1 	B3-2251 	Coverage of Chiropractic Services
15 	240.1.1 	B3-2251.1 	Manual Manipulation
15 	240.1.2 	B3-2251.2 	Subluxation May be Demonstrated by X-Ray or Physician’s
Exam
15 	240.1.3 	B3-2251.3 	Necessity for Treatment
15 	240.1.4 	B3-2251.4 	Diagnosis
15 	240.1.5 	B3-2251.5 	Treatment Parameters
15 	250 	B3-2255 	Medical and Other Health Services Furnished to Inpatients of
Hospitals and Skilled Nursing Facilities
15 	260 	B3-2265 	Ambulatory Surgical Center Services
15 	260.1 	B3-2265.1 	Definition of Ambulatory Surgical Center
15 	260.2 	B3-2265.2 	Ambulatory Surgical Center Services
15 	260.3 	B3-2265.3 	Services Furnished in ASCs Which are Not ASC Facility Services
15 	260.4 	B3-2265.4 	Coverage of Services in ASCs Which are Not ASC Services
15 	260.5 	B3-2266 	List of Covered Ambulatory Surgical Center Procedures

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15 	260.5.1 	B3-2266.1 	Nature and Applicability of ASC List
15 	260.5.2 	B3-2266.2 	Nomenclature and Organization of the List
15 	260.5.3 	B3-2266.3 	Rebundling of CPT Codes
15 	270 	B3-15516C 	AB-01-69,
AB-02-052,
AB 02-053
Telehealth Services
15 	270.1 	CMS 	Eligibility Criteria
15 	270.2 	CMS 	List of Medicare Telehealth Services
15 	270.3 	CMS 	Conditions of Payment
15 	270.4 	CMS 	Payment – Physician/Practitioner at a Distant Site
15 	270.5 	CMS 	Originating Site Facility Fee Payment Methodology
15 	280 	Preventive and Screening Services
(Section heading only with references to other CMS
manuals)
15 	280.1 	A-01-13,
A-01-105
B3 4184-
4184.9
B-01-46 	Glaucoma Screening
15 	280.2 	Colorectal Cancer Screening
(Section heading only)
15 	280.2.1 	B3-4180.1 	Covered Services and HCPCS Codes
15 	280.2.2 	B3-4180.2 	Coverage Criteria

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15 	280.2.3 	B3-4180.3 	Determining Whether or Not the Beneficiary is at High Risk
for Developing Colorectal Cancer
15 	280.2.4 	B3-4180.4 	Determining Frequency Standards
15 	280.2.5 	B3-4180.5 	Noncovered Services
15 	280.3 	A3-3660.10 	B3-4601.1 	Screening Mammography
15 	280.4 	A3-3628.1 	B3-4603.1 	Screening Pap Smears
15 	290 	A3-3158 	B3-2323,
B3-4120.1
HO-260.9 	Foot Care
15 	300 	AB 02-151,
B-01-40
Diabetes Outpatient Self-Management Training Services
15 	300.1 	AB 02-151,
B-01-40
Coverage Requirements
15 	300.2 	AB 02-151,
B-01-40
Certified Providers
15 	300.3 	AB 02-151,
B-01-40
Frequency of Training
15 	300.4 	AB 02-151,
B-01-40
Outpatient Diabetes Self-Management Training
15 	300.5 	AB 02-151,
B-01-40
Bill Processing Requirements