Treatments End and Resume Later
If treatment sessions end and then resume later, Medicare will pay for the additional fractions in
accordance with the above payment schedule. For example, if eight additional treatments are
provided to the patient, then Medicare Part B would pay for two weekly units.
If the number of treatments billed is either three or four, Medicare will pay for it as an entire
weekly treatment only if it occurs upon the completion of the treatment course. However,
if only two additional treatments were given after a treatment session ends, then Medicare Part
B would not make any additional payment.
Entire Treatment Consists of One or Two Treatments
If only one or two treatments were needed for the entire treatment of the patient, then Medicare
Part B would pay 1/2 of the payment allowable for five fractions, provided these were the only
treatments given. Use code 77431 to bill for one or two treatments.
Various Levels of Treatment Needed
There are situations in which patients receive a mixture of simple, intermediate and complex
treatment management services during the course of a treatment. In such cases, Medicare will
pay for the management code that represents the majority of the fractions furnished during the
five-fraction week. For example, an intermediate weekly treatment management service is
payable when, in a grouping of five fractions, the provider performs three intermediate and two
Interruption of Treatment
Medicare considers a new treatment course to have begun if there has been a 30-day
interruption in the patient’s treatment that determines payment.
Example 1: If a provider ends treatment with two fractions and the patient starts treatments
again in 35 days, the provider should not include the previous two fractions with the new
treatments because a new treatment period has begun.
Example 2: If a provider ends treatment with two fractions and treatments begin again within
30 days, then the provider would include the previous two fractions with the current treatment
course and Medicare would pay for them.
Example 3: If the provider bills eight fractions (i.e., one week plus 3 fractions) indicating it was
the end of the patient’s treatment, Medicare would pay the provider for two weeks of treatment.
If the provider bills for two additional treatments before the 30-day period has ended, Medicare
would not pay for the two treatments because the provider has already been paid, in effect, for
Dates of Service
If a patient’s dates of service span a calendar year, providers must indicate the exact dates of
service to ensure proper payment of the claim.