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As such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit coverage. Additional Information ** Medical supplies and medications that are used in conjunction with a home health care visit are covered as part of that visit.

COVERAGE RATIONALE Indications for Coverage The services being requested must meet all of the following: ** Be ordered and directed by a treating practitioner or specialist (M. Some examples are, but not limited to, surgical dressing, catheters, syringes, irrigation devices.

All Medicare benefits are determined by medical necessity, which means that clinicians must provide care that is justifiably reasonable and necessary according to evidence-based clinical standards of care.

The definition of “reasonable and necessary” varies based on both National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).

The MAC may have told them that services listed as excluded under the SNF consolidated billing rules should be billed on a separate outpatient claim, type of bill (TOB) 85X.

However, a , TOB 18X, because the CAH is paid cost for its swing bed services.

To learn more about providing Medicare patients with services that are not medically necessary, click here.

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** Eligible physical, occupational and speech therapy received in the home from a Home Health Agency is covered under the Home Health Care section of the member’s certificate of coverage and/or summary of benefits.“Our long term goal is to phase in other service centers across the state, ultimately reducing the number of offices.” With the new accommodations, the agency consolidated 11 out-stationed SOBRA workers into one location with the Mobile district office staff.Clerical staff provides customer service, answer phones and make it possible for the SOBRA workers to concentrate on their caseloads.Although the CT scan is considered a major category and is an “excluded” service under the SNF PPS consolidated billing requirements, CAHs are exempt from using the list and services provided while the patient is in a CAH’s swing bed should be included on the swing bed claim, regardless of the reason for the service, the findings, or whether additional services were required.In the past, we’ve covered similar scenarios as well, and most people say that the guidance we presented conflicts with guidance they have received from their Medicare administrative contractor (MAC).




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