Medicare Coverage Issues

OSMO April 11, 2015

Medicare Services

• Services Must be Medically Necessary - Provider Attestation on Claim - Supportive Documentation in Patient Chart

Infusion Services

• Infusion Services Only-Provider Attestation to Medically Necessary-Supportive Documentation in Patient Chart• What is the nature of the documentation?

Infusion Services (2)

• E & M plus• Infusion Services

Modifier 25

• E & M service beyond other service provided beyond preoperative or post operative care associated with procedure

• E & M may be prompted by the symptom OR condition for which the procedure service was provided. Separate Dx NOT required

• The circumstance may be reported by adding Modifier 25 to the appropriate Level of E&M

Physician Work

• Infusion Services- Supervisory in Nature– No Face to Face time with patient and consists of

-Provision of an Order-‘Incident to’ requirement: to be immediately

available in suite for nursing questions or problems

Physician Work

• E & M Visit– PreService-Reviewing medical history and other

information– Intra-Service- Direct Face to Face for detailed

history including response to treatment at last visit. Physical Exam. Consider relevant data, formulate diagnosis and update and manage treatment plan and discuss with patient.

– Post service- Documentation and correspondence, care coordination

Documentation Issues

• Infusion Services documentation by OCN• E & M documentation by Qualified Provider– Attention to Medically Necessary provisions– Diagnosis need not be different but reason

prompting the E&M service must be separately identified