What Is Covered Under Medicare Part B

In general, the Medicare program is designed only to provide payment for services that are considered to be medically reasonable and necessary to the overall diagnosis and treatment of a patient's condition. This means for every service submitted, the provider must indicate the specific sign, symptom or patient complaint necessitating the service. Supporting documentation for services that are performed and submitted must be present in the patient's medical record.

While a service or test performed may be considered good medical practice, the Medicare program prohibits reimbursement of services absent symptoms or complaints. Such services are generally considered screening services or routine/preventative in nature and are noncovered.*

Medicare covers many preventive services at no cost to your patients. Encourage patients to take advantage of appropriate preventive services to prevent and find diseases early, when treatment works best. Use the CMS Medicare Preventive Services Tool for coverage and billing information for each service.

Covered Part B service categories are outlined in the CMS Internet Only Manual, Publication 100-1, Chapter 1, Section 10.3 (PDF, 120 KB).

References

• Social Security Act:
  • Section 1862(a)(1)(A) — definition of "reasonable and necessary"
  • Sections 1861(s)(2)(A) and 1861(s)(2)(B) — clarification regarding self-administered drugs
• CMS Pub. 100-01, chapter 1, section 10.3 — Supplementary Medical Insurance (Part B) — A Brief Description (PDF, 120 KB)
• Resources for people with Medicare — Medicare & You Handbook