HI 00610.030 Physicians' Services

A. General

Physicians' services mean the professional services performed by a physician or physicians for a patient including diagnosis, therapy, surgery, and consultation. The services must be rendered by the physician. A service may be considered to be a physician's service where the physician either examines the patient in person or is able to visualize some aspect of the patient's condition without the interposition of a third person's judgment. Direct visualization is possible by means of X-rays, electrocardiogram and electroencephalogram tapes, tissue samples, etc. Thus, for example, the interpretation by a physician of an actual electrocardiogram or electroencephalogram reading that has been transmitted via telephone (i.e., electronically rather than by means of a verbal description) is a covered service.

Professional services of the physician are covered if provided within the United States, and may be performed in a home, office, institution, or at the scene of an accident. A patient's home is anywhere he makes his residence, e.g., a home for the aged, a nursing home, a relative's home, etc.

Where inpatient services in a foreign hospital are covered, payment may also be made for (1) physicians' services rendered to the beneficiary while he is an inpatient, and (2) physician's services rendered to the beneficiary outside the hospital on the day of his admission as an inpatient, provided the services were for the same condition for which the beneficiary was hospitalized. This provision became effective for services rendered on and after 1/1/73.

The definition of “physician,” for purposes of coverage of services furnished outside the United States, is expanded to include a foreign practitioner of one of the practices described in HI 00401.295 provided the practitioner is legally licensed to practice in the country in which the services were rendered. (See HI 00610.250 for coverage of ambulance services in connection with a covered foreign hospital stay.)

B. Telephone services

Services by means of a telephone call between physicians and beneficiaries (including those in which the physician provides advice or instructions to or on behalf of a beneficiary) and visits for the sole purpose of obtaining or renewing a prescription the need for which was previously determined, so that no examination of the patient is performed, are not covered services.

C. Consultations

A consultation is reimbursable when it is a professional service furnished a patient by a second physician or consultant at the request of the attending physician. Such a consultation includes the history and examination of the patient as well as the written report, which is furnished to the attending physician for inclusion in the patient's permanent medical record. These reports must be prepared and submitted for retention in provider records when they involve patients of institutions responsible for maintaining such records, and in attending physicians' office records for other patients.

D. Concurrent care

Concurrent care exists where services more extensive than consultative services are rendered by more than one physician during a period of time. The reasonable and necessary services of each physician rendering concurrent care could be covered where each is required to play an active role in the patient's treatment, for example, because of the existence of more than one medical condition requiring diverse specialized medical services.

In order to determine whether concurrent physicians' services are reasonable and necessary, the carrier decides (1) whether the patient's condition warrants the services of more than one physician on an attending (rather than consultative) basis, and (2) whether the individual services provided by each physician are reasonable and necessary.

While it would not be highly unusual for concurrent care performed by physicians in different specialties (e.g., a surgeon and an internist) or by physicians in different subspecialties of the same speciality (e.g., an allergist and a cardiologist) to be found reasonable and necessary, the need for such care by physicians in the same specialty or subspecialty (e.g., two internists or two cardiologists) would occur infrequently since in most cases both physicians would possess the skills and knowledge necessary to treat the patient. However, circumstances could arise which would necessitate such care. For example, a patient may require the services of two physicians in the same specialty or subspecialty when one physician has further limited his practice to some unusual aspect of that specialty, e.g., tropical medicine. Similarly, concurrent services provided by a family physician and an internist may or may not be found to be medically necessary, depending on the circumstances of the specific case. If it is determined that the services of one of the physicians are not warranted by the patient's condition, payment may be made only for the other physician's (or physicians') services.

Once it is determined that the patient requires the active services of more than one physician, the individual services must be examined for medical necessity, just as where a single physician provides the care. For example, even if it is determined that the patient requires the concurrent services of both a cardiologist and a surgeon, payment may not be made for any services rendered by either physician which, for that condition, exceed normal frequency or duration, unless, of course, there are special circumstances requiring the additional care.

The carrier must also assure that the services of one physician do not duplicate those provided by another, e.g., where the family physician visits during the post-operative period primarily as a courtesy to the patient.

Hospital admission services performed by two physicians for the same beneficiary on the same day could represent reasonable and necessary services, provided, as stated above, that the patient's condition necessitates treatment by both physicians. The level of difficulty of the service billed for may vary between the physicians, depending on the severity of the patient. For example, the admission services performed by a physician who has been treating a patient over a period of time for a chronic condition would not be as involved as the services performed by a physician who has had no prior contact with the patient and who has been called in to diagnose and treat a major acute condition.

A correct coverage determination can be made on a concurrent care case only where the claim is sufficiently documented for the carrier to determine the role each physician played in the patient's care (i.e., the condition or conditions for which the physician treated the patient). If in any case the role of each physician involved is not clear, the carrier requests clarification.

E. Patient-initiated second opinions

Patient-initiated second opinions relating to the medical need for surgery, or for major nonsurgical diagnostic and therapeutic procedures (e.g., invasive diagnostic techniques such as cardiac catherization and gastroscopy) are covered. In the event that the recommendation of the first and second physician differ, a third opinion is also covered. Second and third opinions are covered even though the surgery or other procedure, if performed, is determined not covered.

Payment (based on the reasonable charge ordinarily allowed for consultations and related services), may be made for the history and examinationof the patient, and for covered diagnostic services required to properly evaluate his need for a procedure and to render a professional opinion.

F. X-ray and EKG interpretation

When a hospital radiologist does the initial interpretation of a radiological exam which he or she or a qualified technician performed on a hospital patient, the interpretation is clearly covered as a physician's service. In addition, when a hospital radiologist interprets an X-ray that has already been interpreted by another physician, that interpretive service almost always constitutes patient care and, thus, would also qualify as a physician's service. The radiologist's interpretation is a specialist's evaluation of the interpretation of the attending physician or the emergency room physician, and the radiologist's findings could affect the course of treatment initiated or cause a new course of treatment to begin. The fact that the particular patient is no longer on the hospital premises at the time the radiologist interprets the X-ray should not be controlling in deciding whether there was a physician's service, since the patient may be recalled. If, on the other hand, the radiologist is interpreting the X-ray solely for “quality control” purposes, e.g., randomly selecting films to appraise the technician's performance, quality of the film or equipment, etc., the service should be considered a hospital service reimbursable under Part A of the Medicare program. These same rules would apply to a cardiologist's diagnostic interpretations previously interpreted by an attending or an emergency room physician.

Part of an attending/emergency room physician's overall workup or treatment of a patient would include the interpretation of an X-ray or EKG ordered by him. Thus, a separate charge would not be allowed for an X-ray or EKG interpretation performed by the attending physician after the hospital's radiologist's or cardiologist's interpretation (including in those terms any physician working in either capacity).

G. Completion of claims forms

Charges for the services of a physician in completing an HCFA-1490, a statement in lieu of an HCFA-1490, or an itemized bill are not covered.

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HI 00610.030 - Physicians' Services - 09/15/1989
Batch run: 05/09/2014