by Jared Staheli
June 25th, 2015
Prior to the enactment of BIPA, reimbursement for Medicare services provided in IHS facilities was limited to services provided in hospitals and SNFs. Effective July 1, 2001, §432 BIPA extended payment to services of IHS physicians and practitioners furnished in hospitals and ambulatory care clinics.
The services that may be paid to IHS physicians and practitioners under the MPFS are as follows:
• Services for which payment is made under §1848 of the Act. Section 1848(j)(3) defines physician services paid under the MPFS. Although anesthesia services are considered to be physician services, these services are not included on the physician fee schedule database. Anesthesia services are covered and are reimbursed using a separate payment method (see §1848(d)(1)(D)). Also, included are diagnostic tests (see §1861(s)(3)), covered drugs and biologicals furnished incident to a physician service (see §1861(s)(2)(A) and (b)) and DSMT services (see 1861(s)(2)(S)).
• Services furnished by a physical therapist (which includes speech-language pathology services furnished by a provider of service) or occupational therapist as described in §1861(p) of the Act for which payment under Medicare Part B is made under the MPFS.
• Services furnished by a registered dietitian or nutrition professional (meeting certain requirements) as defined in §105 of BIPA for MNT services for beneficiaries with diabetes or renal disease.
• Screening mammography services are paid under the MPFS based on the BIPA provision when rendered in a physician’s office.
• Drugs provided by a physician in the office setting are paid using the ASP from the Medicare Part B Drug Pricing File supplied to all carriers and intermediaries by CMS.
• Audiologists can directly bill Medicare but only for diagnostic tests.
• Payment for telehealth services under Medicare Part B are covered as described in Pub. 100-04, Medicare Claims Processing Manual, Chapter12, §190.
• Services furnished by a practitioner described in §1842(b)(18)(C) of the Act for which payment under Medicare Part B is made under the MPFS. The specific nonphysician practitioners included and the appropriate payment percentage of the fee schedule amount are:
Practitioner Services Percentage of Physician Payment
Certified Registered Nurse Anesthetist 50 percent
Certified Registered Nurse Anesthetist 100 percent
Clinical Nurse Specialist 85 percent
Clinical Psychologist 100 percent
Clinical Social Worker 75 percent
Nurse Mid-Wife 65 percent
Nurse Practitioner 85 percent
Nutrition Professional/ Registered Dietitian 85 percent
Occupational Therapist 100 percent
Physical Therapist 100 percent
Physician Assistant 85 percent
See Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, for information on billing by physicians and practitioners.
Subject to national coverage determinations and local coverage determinations (LCDs), pay for services included in the MPFS database that have the following status indicators:
• A = active
• C = carrier-priced code
• R = restricted coverage (if no relative value units (RVUs) are shown, service is carrier priced)
• E = excluded from physician fee schedule by regulation
For more information on status indicators, see Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, §30.2.2.