LCD ID Number: L34539 Status: A-Approved
LCD Title: Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians
Geographic Jurisdiction: Kentucky Other Jurisdictions
Original Determination Effective Date:
Original Determination Ending Date:
Revision Effective Date:
Revision End Date:
CMS National Coverage Policy:
Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. Please see Section 1869(f)(1)(A)(i) of the Social Security Act.
Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:
Title XVIII of the Social Security Act (SSA):
Section 1833(e) of Title XVIII of the Social Security Act prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Section 1861(s)(2)(A) of Title XVIII of the Social Security Act defines 'medical and other health services' as "any of the following items or services: services and supplies (including drugs and biologicals which cannot, as determined in accordance with regulations, be self - administered) furnished as an incident to a physician's professional service, of kinds which are commonly furnished in physicians' offices and are commonly either rendered without charge or included in the physicians' bills;"
Sections 1861(s)(2)(l) and 1861(gg)(l) of Title XVIII "incident to" a certified nurse midwife's (CNMW's) services.
Section 1861(s)(2)(K)(iv) of Title XVIII of the Social Security Act authorizes coverage for services furnished "incident to" a physician assistant's services.
Section 1862(a)(1)(A) of Title XVIII of the Social Security Act excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Code of Federal Regulations:
42 CFR 410.32 states that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license) and Medicare requirements.
42 CFR 410.71 describes coverage of clinical psychologist services and supplies incident to a clinical psychologist.
42 CFR 410.73-410.76 describes coverage of services provided by clinical social workers, physician assistants, nurse practitioners, or clinical nurse specialists.
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:
60.1 Services and Supplies; Incident to Physician's Professional Services
60.2 Services and supplies: Services of Nonphysician Personnel Furnished Incident to Physician's Services
60.3 Incident to Physician's Service in Clinic
60.4 Services Incident to a Physician's Service to Homebound Patients under General Physician Supervision
160 Clinical Psychological Services
170 Clinical Social Worker (CSW) Services
210 Clinical Nurse Specialist (CNS) ServicesCMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1:
70.3 Physician's Office Within an Institution - Coverage of Services and SuppliesCMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12:
110 Physician Assistant (PA) Services Payment Methodology
110.3 PA Billing to Carrier
120 Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS).
120.1 NP and CNS "Direct Billing and Payment"
150 Clinical Social Worker (CSW) Services
160 Independent Psychologist Services
160.1 Payment for Independent Psychologist Services
170 Clinical Psychologist Services.
170.1 Payment for Clinical Psychologist ServicesCMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30:
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