What Medicare has to say about services furnished to immediate
Under Medicare Part B, no payment may be made for services provided by a physician or
supplier to his/her immediate relatives or members of his/her household. This exclusion applies to
items and services rendered by a related physician or supplier, even if the bill or claim is
submitted by an unrelated individual, partnership, or professional corporation. This also includes
services furnished "incident-to" a physician’s professional service, only if the physician who
ordered or supervised the service is an immediate relative of the beneficiary. The following
degrees of relationship are included in the definition of immediate relative:
Husband and wife.
Natural or adoptive parent, child, and sibling.
Step-parent, stepchild, stepbrother, and stepsister.
Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law.
Grandparent and grandchild.
Spouse of grandparent and grandchild.
Please note: A brother-in-law or sister-in-law relationship does not exist between a physician and
the spouse of his wife’s brother or sister; a father-in-law or mother-in-law relationship does not
exist between a physician and his/her spouse’s stepfather or stepmother. A step-relationship and
in-law relationship continue to exist even if the marriage upon which the relationship is based
terminates through divorce or through the death of one of the parties. Members of the household
are considered persons sharing a common abode with the patient as part of a single family unit,
including those related by blood, marriage, or adoption, domestic employees, and others who live
together as a single family unit. A mere roomer or boarder is not included.
Site of interest:
This site is designed to provide you with the appropriate tools to aid in:
The proper submission of Medicare claims.
The appropriate payment for services rendered to Medicare beneficiaries.
Below is a list of free, downloadable courses offered from HCFA:
"Fraud and Abuse"
"ICD-9-CM Diagnosis Coding"
"Medicare Secondary Payer"
"Front Office Management"
"Intro to the World of Medicare"
These courses are designed to be completed at the student’s own pace. Each course will take
approximately 30 minutes to 1 hour to finish depending on the individual. At the completion of
each course, the student will take a self-assessment knowledge test. Once the test is completed
a "Certificate of Completion" is available and can be printed.
News from BWC…
The managed care organizations, in collaboration with BWC, developed standardized prior
authorization and presumptive approval guidelines that will make it possible for providers, in
many cases, to provide services during the first 45 days following an injury without obtaining prior
authorization from the MCO.
The Presumptive Approval Guidelines, which were effective January 1, 2001, allows physicians to
provide the following services without a pre-authorization:
10 physical medicine visits including osteopathic, chiropractic, physical therapy and
Diagnostic studies, including x-rays, CAT scans, MRI scans, and EMG;NCV.
Injections up to three soft tissue or joint injections (does not include epidural injections).
E/M services and consultation services.
In addition, the following criteria must be met prior to initiating any or all of the aforementioned
The provider shall file the First Report of Injury with the MCO.
The provider shall complete and file the C-9 Treatment Plan with the MCO.
The provider shall notify the MCO within 24 hours of treatment if the injured worker will be off
work for more than 2 calendar days
Below is a list of services that do not fall in the presumptive approval parameters and still require
Hospital Inpatient treatment, including surgery and outpatient / ASC surgery.
Skilled Nursing Facility / Extended Care Facility.
Home Health Agency services.
Correct billing for KOH preps
When billing for KOH preps please remember that Q0112 has been created for Medicare billing
purposes. For all non-Medicare patients, CPT code 87220 should be used.
Are you currently billing physicals to Medicaid with no
According to Medicaid guidelines, physicals are non-covered services for patients over the age of
21. However, Medicaid will pay for an annual pap for those patients over the age of 21 using an
Evaluation and Management code from the range 99212-99215 for established patients and
99201-99205 for new patients. ICD-9 code V72.3 "Gynecological Examination" must be
submitted with the claim. Keep in mind, this is the only carrier which requires annual paps to be
billed with regular E/M codes using the V code as the primary diagnosis.
UHC vs. 790.0 Abnormal lab chemistry
Finally, we have direction from our local UHC carrier on how to handle those dreaded 790.6
"Abnormal lab chemistry" denials for hyperglycemia.
According to our UHC representative, in order to obtain reimbursement for claims that were
previously denied due to using the 790.6 code we need to send a copy of the EOB to Dr.
Johnson, UHC Medical Director. Dr. Johnson will review these claims on a case-by-case basis
and sign off. Once approval is obtained from the Medical Director the claims will be reprocessed
for payment. To simplify the matter, please forward all adjustment code 4 denials for 790.6 to
Judy McNichols. The EOB’s will be sent to UHC on a monthly basis. We will also monitor
resubmitted claims to ensure adequate payment.