[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR418.304]



[Page 930]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 418_HOSPICE CARE--Table of Contents

 

                   Subpart G_Payment for Hospice Care

 

Sec. 418.304  Payment for physician and nurse practitioner services.



    (a) The following services performed by hospice physicians and nurse 

practitioners are included in the rates described in Sec. 418.302:

    (1) General supervisory services of the medical director.

    (2) Participation in the establishment of plans of care, supervision 

of care and services, periodic review and updating of plans of care, and 

establishment of governing policies by the physician member of the 

interdisciplinary group.

    (b) For services not described in paragraph (a) of this section, a 

specified Medicare contractor pays the hospice an amount equivalent to 

100 percent of the physician's reasonable charge for those physician 

services furnished by hospice employees or under arrangements with the 

hospice. Reimbursement for these physician services is included in the 

amount subject to the hospice payment limit described in Sec. 418.309. 

Services furnished voluntarily by physicians are not reimbursable.

    (c) Services of the patient's attending physician, if he or she is 

not an employee of the hospice or providing services under arrangements 

with the hospice, are not considered hospice services and are not 

included in the amount subject to the hospice payment limit described in 

Sec. 418.309. These services are paid by the carrier under the 

procedures in subparts D or E, part 405 of this chapter.

    (d) Payment for hospice pre-election evaluation and counseling 

services. The intermediary makes payment to the hospice for the services 

established in Sec. 418.205. Payment for this service is set at an 

amount established under the physician fee schedule, for an office or 

other outpatient visit for evaluation and management associated with 

presenting problems of moderate severity and requiring medical decision-

making of low complexity other than the portion of the amount 

attributable to the practice expense component. Payment for this pre-

election service does not count towards the hospice cap amount.

    (e)(1) Effective December 8, 2003, Medicare pays for attending 

physician services provided by nurse practitioners to Medicare 

beneficiaries who have elected the hospice benefit and who have selected 

a nurse practitioner as their attending physician. This applies to nurse 

practitioners without regard to whether they are hospice employees.

    (2) Nurse practitioners may bill and receive payment for services 

only if the--

    (i) Nurse practitioner is the beneficiary's attending physician as 

defined in Sec. 418.3;

    (ii) Services are medically reasonable and necessary;

    (iii) Services are performed by a physician in the absence of the 

nurse practitioner; and

    (iv) Services are not related to the certification of terminal 

illness specified in Sec. 418.22.

    (3) Payment for nurse practitioner services are made at 85 percent 

of the physician fee schedule amount.



[48 FR 56026, Dec. 16, 1983, as amended at 69 FR 66426, Nov. 15, 2004; 

70 FR 45145, Aug. 4, 2005]