HI 00401.295 Physician Defined

Citations:

Social Security Act—Sec. 1861(r)

Regulations No. 5—405.231(a),(b)

A. General

Physician means doctor of medicine, doctor of osteopathy (including osteopathic practitioner), doctor of dental surgery or dental medicine (within the limitations in C.), doctor of podiatric medicine (within the limitations in D.), or doctor of optometry (within the limitations of F.), or a chiropractor (within the limits of G.), legally authorized to practice by a State in which he performs this function. The services performed by a physician within these definitions are subject to any limitations imposed by the State on the scope of practice.

In all States, the issuance by the State of a license to practice medicine constitutes legal authorization. Temporary State licenses also constitute legal authorization to practice medicine. If State law authorizes local political subdivisions to establish higher standards for medical practitioners than those set by the State licensing board, such local standards will be issued in determining whether a particular physician has legal authorization. If State licensing law limits the scope of practice of a particular type of medical practitioner, only the services within these limitations will be covered.

NOTE: The term “physician” does not include such practitioners as a Christian Science practitioner, or naturopath.

B. Doctors of medicine and osteopathy

The requirement that a doctor of medicine must be legally authorized to practice medicine and surgery by the State in which he performs his services is met where a physician is licensed by the State to practice medicine and surgery.

A doctor of osteopathy who is legally authorized to practice medicine and surgery by the State in which he performs his services qualifies as a physician. In addition, a licensed osteopath or osteopathic practitioner qualifies as a “physician” to the extent that he performs services within the scope of his practice as defined by State law. For example, in some States osteopaths and osteopathic practitioners are limited in their practice to the manipulation of bones and muscles; such legally authorized services are covered.

C. Dentists

A dentist is a “physician” under the health insurance program if he is a doctor of dental surgery or dental medicine legally authorized to practice dentistry by the State in which he performs his services. However, a dentist is a physician only with respect to surgery related to the jaw or any structure contiguous to the jaw, or the reduction of any fracture of the jaw or any facial bone. In general, “the jaw or any structure contiguous to the jaw” includes structures of the facial area below the eyes; e.g., mandible, teeth, gums, tongue, palate, salivary glands, sinuses, etc.

Because of the general exclusion of payment for dental services, payment for the services of dentists is also limited to those surgical procedures which are not primarily provided for the care, treatment, removal, or replacement of teeth or structures directly supporting teeth. The coverage or exclusion of any given dental service is not affected by the professional designation of the “physician” rendering the service; i.e., an excluded dental service remains excluded and a covered dental service is still covered whether furnished by a dentist or a doctor of medicine.

Effective with admissions on or after 1/1/73, the 1972 Amendments authorize the dentist caring for the patient to certify (without corroborating certification by a physician) that because of the patient's underlying medical condition and clinical status, he requires hospitalization for performance of excluded dental procedures.

D. Podiatrists

A podiatrist is included within the definition of “physician” but only with respect to those functions which he is legally authorized to perform in the State in which he performs them. This means that the professional services provided by a podiatrist within the scope of his applicable State license (except those services which are specifically excluded) are “physician's services” reimbursable on a reasonable charge basis under Part B.

Podiatrists may hold any of the following professional degrees of which the first three are the most common: Pod.D or D.P. (Doctor of Podiatry), D.S.C. (Doctor of Surgical Chiropody), D.P.M. (Doctor of Podiatric Medicine), D.S.P. (Doctor of Surgical Podiatry), Graduate in Podiatry, Master Chiropodist, Graduate Chiropodist, or in a very few instances another podiatry degree. Within a particular State, all individuals holding any of these degrees are licensed to perform the same functions; however, there are variations from State to State as to the authorized scope of podiatric practice.

A podiatrist is considered a “physician” for any of the following purposes:

  1. for making the required physician certification and recertifications of the medical necessity for Part A and Part B provider services;

  2. for the purpose of establishing and periodically reviewing a home health plan of treatment; and for purposes of constituting a member of a Utilization Review (UR) committee but only if:

    1. the performance of these functions is consistent with the policy of the institution or agency with respect to which he performs them;

    2. the podiatrist is legally authorized by the State to perform such functions; and

    3. at least two of the physicians on the UR committee are doctors of medicine or osteopathy.

E. Physicians in federal hospitals

There are many physicians performing services in hospitals operated by the Federal Government—military hospitals, Veterans Administration hospitals, and Public Health Service hospitals. Normally the services provided by a physician in a Federal hospital are not reimbursable except when the hospital provides services to the public generally as a community institution. Such a physician working in the scope of his Federal employment may be considered as coming within the statutory definition of “physician” even though he may not have a license to practice in the State in which he is employed.

F. Optometrists

A doctor of optometry, legally authorized to practice optometry by the State in which he performs such function, becomes a “physician” as defined in the law but only for the purpose of attesting to the patient's need for prosthetic lenses. Thus, payment may be made for necessary prosthetic lenses whether prescribed by an optometrist or other physician authorized to do so. This change applies to claims for prosthetic lenses furnished on and after October 30, 1972.

G. Chiropractors

1. General

A licensed chiropractor who meets uniform minimum standards (see 3. below) is a physician with respect to specified services furnished on and after July 1, 1973. Coverage extends only to treatment by means of manual manipulation of the spine to correct a subluxation demonstrated by x-ray, provided such treatment is legal in the state where performed.

No coverage is included for chiropractic x-rays or other diagnostic or therapeutic services.

2. Licensure and authorization to practice

A chiropractor must be licensed or legally authorized to furnish chiropractic services by the State or jurisdiction in which he provides them. Reimbursement may not be made for chiropractic services rendered in the State of Louisiana where the practice is not legal.

3. Uniform minimum standards

  1. Chiropractors licensed or authorized to practice prior to July 1, 1974, and those individuals who commenced their studies in a chiropractic college beforethat date must meet all of the following minimum standards to render reimbursable services under the program:

    1. Preliminary education equal to the requirements for graduation from an accredited high school or other secondary school; and

    2. Graduation from a college of chiropractic approved by the State's chiropractic examiners which included the completion of a course of study covering a period of not less than 3 school years of 6 months each year. The student must have been in actual continuous attendance taking adequate courses of study in the subjects of anatomy, physiology, symptomatology and diagnosis, hygiene and sanitation, chemistry, histology, pathology, and principles and practice of chiropractic including clinical instruction in vertebral palpation, nerve tracing and adjusting; and

    3. Passage of an examination prescribed by the State's chiropractic examiners covering the subjects listed in 2) above.

  2. Individuals commencing their studies in a chiropractic college after June 30, 1974, must meet all of the following additional requirements:

    1. Satisfactory completion of 2 years of pre-chiropractic study at the college level.

    2. Satisfactory completion of a 4 year course of 8 months each year (instead of a 3 year course of 6 months each year) at a college or school of chiropractic which includes not less than 4,000 hours in the scientific and chiropractic courses specified in subparagraph a. 2) above plus courses in the use and effect of x-ray and chiropractic analysis; and

    3. The practitioner must be over 21 years of age.


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HI 00401.295 - Physician Defined - 04/06/2015
Batch run: 04/06/2015
Rev:04/06/2015