CFR > Title 42 - Public Health > CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES > SUBCHAPTER B—MEDICARE PROGRAM (parts 405 to 426) > PART 419—PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT DEPARTMENT SERVICES > SUBPART B—Categories of Hospitals and Services Subject to and Excluded From the Hospital Outpatient Prospective Payment System (§419.20 to §419.22) > 419.22—Hospital outpatient services excluded from payment under the hospital outpatient prospective payment system.

419.22—Hospital outpatient services excluded from payment under the hospital outpatient prospective payment system.

The following services are not paid for under the hospital outpatient prospective payment system:
(a) Physician services that meet the requirements of § 415.102(a) of this chapter for payment on a fee schedule basis.
(b) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act.
(c) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act.
(d) Certified nurse-midwife services, as defined in section 1861(gg) of the Act.
(e) Services of qualified psychologists, as defined in section 1861(ii) of the Act.
(f) Services of an anesthetist as defined in § 410.69 of this chapter.
(g) Clinical social worker services as defined in section 1861(hh)(2) of the Act.
(h) Outpatient therapy services described in section 1833(a)(8) of the Act.
(i) Ambulance services, as described in section 1861(v)(1)(U) of the Act, or, if applicable, the fee schedule established under section 1834(l).
(j) Except as provided in § 419.22(b)(11), prosthetic devices, prosthetics, prosthetic supplies, and orthotic devices.
(k) Except as provided in § 419.2(b)(10), durable medical equipment supplied by the hospital for the patient to take home.
(l) Clinical diagnostic laboratory services.
(m) Services for patients with ESRD that are paid under the ESRD composite rate and drugs and supplies furnished during dialysis but not included in the composite rate.
(n) Services and procedures that the Secretary designates as requiring inpatient care.
(o) Hospital outpatient services furnished to SNF residents (as defined in § 411.15(p) of this chapter) as part of the patient's resident assessment or comprehensive care plan (and thus included under the SNF PPS) that are furnished by the hospital “under arrangements” but billable only by the SNF, regardless of whether or not the patient is in a Part A SNF stay.
(p) Services that are not covered by Medicare by statute.
(q) Services that are not reasonable or necessary for the diagnosis or treatment of an illness or disease.
(r) Services defined in § 419.21(b) that are furnished to inpatients of hospitals that do not submit claims for outpatient services under Medicare Part B.
(s) Effective December 8, 2003, screening mammography services and effective January 1, 2005, diagnostic mammography services.
[65 FR 18542, Apr. 7, 2000, as amended at 66 FR 59922, Nov. 30, 2001; 69 FR 65863, Nov. 15, 2004]