LCD ID Number: L35068 Status: A-Approved
LCD Title: Evaluation and Management Services Provided in a Nursing Facility
Geographic Jurisdiction: Delaware Other Jurisdictions
Original Determination Effective Date:
Original Determination Ending Date:
Revision Effective Date:
Revision End Date:
CMS National Coverage Policy:
This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for evaluation and management services (E/M) provided in a nursing facility. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for E/M services provided in a nursing facility and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:
- CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, Section 70.3 Physician’s Office within an Institution - Coverage of Services and Supplies Incident to a Physician’s Services.
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.10 Consultation Services.
- Chapter 12, Section 30.6.13 Nursing Facility Services.
- CMS IOM 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD.
Change Requests References:
Change Request (CR) 7405 CP, of January 01, 2011
Federal Registration References:
- Title 42 Code of Federal Regulations (CFR) Chapter IV Subchapter B Part 483 section 483.30 Physician services
Social Security Act (Title XVIII) Standard References:
- Title XVIII of the Social Security Act, Section 1819 (b)(6)(A). The section outlines statute for Skilled Nursing Facilities.
- Title XVIII of the Social Security Act, Section 1919 (b)(6)(A). This section outlines statue for Nursing Facility.
- Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
- Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
- Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
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