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CPT codes,
descriptions and other data only are copyright 2007 American Medical
Association (or such other date of publication of CPT). All Rights
Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology,
(CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. © 2002,
2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
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Title XVIII of the
Social Security Act, Section 1862 (a)(1)(A). This
section excludes coverage of items or services that are not reasonable and
necessary for the diagnosis or treatment of illness or injury or to improve
the functioning of a malformed body member.
Title XVIII of the Social Security Act, Section 1862 (a)(7).
This section prohibits Medicare payment for any expenses on items and
services incurred for routine physical examinations.
Title XVIII of the Social Security Act, Section 1833 (e). This section
prohibits Medicare payment for any claim that lacks the necessary
information to process the claim.
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Federal legislation
has set forth requirements for skilled nursing facilities (SNF) to
participate in the Medicare program, and for nursing facilities NFs) to participate in the Medicaid program. One
requirement is that each SNF and NF resident have an initial and a periodic
comprehensive assessment, in order to institute a comprehensive care plan
that meets the resident’s medical, nursing, mental, and psychological
needs. The care plan must be developed and revised by an interdisciplinary
team that includes at least the attending physician and a registered nurse
with responsibility for the resident. The components of the care plan are
then documented on the physician’s order sheet, which is signed by the
physician and the nurse.
The physician's order sheet is used to list the medications, diet,
activities and hygienic needs of a resident of SNF or NF. However, it has
also been used to list various providers
specialties which may render services and procedures to the resident, and
various screening services which may be routinely performed on the
resident. Provider specialties have often included audiology,
optometry, podiatry, psychology, psychiatry, physical therapy, speech
therapy and occupational therapy. Routine screening services have often
included laboratory tests, electrocardiograms and portable chest x-rays.
These "PRN" or standing orders for care by other provider
specialties and provision of routine screening services have resulted in
considerable overutilization, and are being
addressed by this policy.
Consultations and services ordered on a PRN basis take away from the
physician prerogative to have made a decision after evaluating the patient.
The decision cannot be passed on to other individuals who are not
practitioners within the scope of Medicare's definition.
This policy applies to a "PRN" or "standing" order for
any provider specialty or for any routine screening service (except as otherwise
specified in manual instructions, e.g. MCM 2049.4 permits a standing order
for pneumococcal pneumonia vaccinations) whether
the order is written on the physician's order sheet integral to the
resident's comprehensive care plan, or elsewhere in the resident's medical
record.
This intermediary will not cover any service or procedure that is performed
on a resident of a SNF or NF unless:
1. The resident's attending physician evaluates the resident and authorizes
the order for the service or procedure, or for the
referral of the resident to another provider specialty, or
2. Unless another physician, whose attendance is requested by the
resident's family member or legal guardian, and authorizes the order for
the service or procedure.
3. The attending physician must be notified of any change in the resident's
physical, mental or psychosocial status, or of the need to alter the
resident's treatment significantly.
Thus, Medicare will not cover Evaluation and Management (E&M) services,
procedure, testing or other services rendered in a nursing home in response
to a PRN standing order. Note that this does not apply to PRN medications.
Parameter orders (e.g. "CBC and call MD if temperature is over
101.5") are appropriate only if the physician is then promptly
informed and involved in the ongoing plan of care.
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