TL;DR
Chapter 15 of the Medicare Benefit Policy Manual (Pub. 100-02) defines what Part B covers as medical and other health services. It sets the coverage conditions for physician and nonphysician practitioner services, services incident to a physician's service, drugs and biologicals, diagnostic tests and the ordering rules behind them, durable medical equipment and prosthetics, outpatient therapy, chiropractic care, and many named benefits from cardiac rehabilitation to home infusion therapy.
Chapter 15 at a glance
- Current revision
- Rev. 13889
- Issued July 30, 2026
- Effective
- August 28, 2026
- Implemented August 28, 2026
- Sections
- 223
- 37 top-level sections
- Transmittals in history
- 127
- Listed at the end of the chapter
- Monthly searches
- 480
- Google Ads, US, October 2026
What chapter 15 governs for billing
Chapter 15 answers whether a Part B service is covered at all; the Claims Processing Manual then explains how to bill it. Section 30 defines physician services and who counts as a physician, with sections on teaching physicians, interns and residents, optometrists and chiropractors. Section 40 covers private contracts and physicians who opt out of Medicare. Section 50 sets the rules for drugs and biologicals: a drug must be reasonable and necessary for its use, furnished incident to a physician's service and of a type that is not usually self-administered, and section 50.2 explains how contractors decide which drugs are self-administered and therefore excluded.
Section 60 is the incident-to rule that most practices look up. Services and supplies furnished by auxiliary personnel are covered as incident to a physician's or nonphysician practitioner's service when they are an integral, though incidental, part of a course of treatment the physician personally initiated, furnished in the office under direct supervision and billed by the supervising practitioner; 60.4 relaxes supervision for certain services to homebound patients. Section 80 covers diagnostic tests: laboratory, psychological and neuropsychological testing, audiology, portable x-ray, bone mass measurement, and in 80.6 the requirement that a test be ordered by the treating physician or practitioner who uses the result.
The middle of the chapter defines the equipment benefits: surgical dressings and casts (100), durable medical equipment (110), prosthetic devices (120), braces and artificial limbs (130), therapeutic shoes for diabetes (140) and lymphedema compression items (145). Sections 160 to 210 cover clinical psychologists, clinical social workers, nurse-midwives, physician assistants, nurse practitioners and clinical nurse specialists. Section 220 and 230 set the outpatient therapy rules: a certified plan of care, the physician or practitioner's certification within 30 days of the first treatment, and documentation. Later sections cover pulmonary and cardiac rehabilitation (231 and 232), chiropractic manipulation to correct a subluxation (240), ambulatory surgical center services (260), preventive services (280), foot care (290), home infusion therapy (320) and marriage and family therapists and mental health counselors (330 and 340).
Sections billing teams use most
Section numbers and headings are CMS's; the notes are ours. Each section number opens the official chapter 15 PDF at the page where that section starts.
| Section | CMS heading | Why it matters |
|---|---|---|
| 50.2 | Determining Self-Administration of Drug or Biological | How contractors decide a drug is usually self-administered and excluded from Part B. |
| 60.2 | Services of Nonphysician Personnel Furnished Incident To Physician's Services | Services of nonphysician personnel furnished incident to a physician's service, under direct supervision. |
| 80.6 | Requirements for Ordering and Following Orders for Diagnostic Tests | Diagnostic tests must be ordered by the treating physician or practitioner who uses the results. |
| 110.8 | DMEPOS Benefit Category Determinations | DMEPOS benefit category determinations, the section CMS revised most recently. |
| 190 | Physician Assistant (PA) Services | Coverage of physician assistant services. |
| 220.1.3 | Certification and Recertification of Need for Treatment and Therapy Plans of Care | Certification and recertification of therapy plans of care. |
| 240.1.2 | Subluxation May Be Demonstrated by X-Ray or Physician's Exam | How a subluxation must be demonstrated for chiropractic coverage. |
How chapter 15 shows up on claims and denials
Chapter 15 failures are coverage failures, so the remittance usually carries reason code 50 or 96. A service that does not meet the incident-to conditions, such as one furnished without the required supervision or for a new problem the physician has not seen, is not covered as billed under the physician's number. A drug on the contractor's self-administered drug exclusion list is denied as noncovered, and a diagnostic test without an order from the treating practitioner fails the ordering requirement.
Many chapter 15 benefits are narrowed further by national and local coverage determinations, so denials often carry remark N386 for an NCD or N115 for an LCD. When that happens, the appeal needs documentation that the patient met the policy's indications, not just evidence that the service falls inside the chapter 15 benefit category.
Codes you are likely to see on the remittance when a claim runs into this chapter's rules. The code pages explain each code's meaning, root causes and the usual fix.
| Code | Type | When it appears |
|---|---|---|
| 50 | Claim adjustment reason code | Service not reasonable and necessary under the benefit or coverage policy. |
| 96 | Claim adjustment reason code | Non-covered charge, for example an excluded self-administered drug. |
| 204 | Claim adjustment reason code | Service not covered under the patient's current benefit plan. |
| N115 | Remark code | Decision based on a Local Coverage Determination. |
| N386 | Remark code | Decision based on a National Coverage Determination. |
Current revision and recent transmittals
The chapter PDF posted on cms.gov is current through Rev. 13889, issued July 30, 2026, effective August 28, 2026, implemented August 28, 2026 (change request 14535). That revision changed section 110.8 (DMEPOS Benefit Category Determinations).
The newest rows of the transmittal history printed at the end of the chapter (127 revisions in all). Rows whose subject could not be read reliably from the PDF table are left out; the PDF has the complete list.
| Revision | Issued | Subject | CR |
|---|---|---|---|
| R13295BP | July 25, 2025 | Omnibus Change Request (CR) Covering Updates for the Medicare Physician Fee Schedule (MPFS) Rule 2025: (1) Updates to Colorectal Cancer Screening and Hepatitis B Vaccine Policies | 14031 |
| R13108BP | April 11, 2025 | Manual Updates to Chapter 17 of the Medicare Claims Processing Manual and Chapter 15 of the Medicare Benefit Policy Manual to Reflect Policies Finalized in the Calendar Year (CY) Physician Fee Schedule Final Rule | 13943 |
| R13051BP | January 16, 2025 | Qualifications for Speech-Language Pathologists Furnishing Outpatient Speech-Language Pathology Services | 13922 |
| R12865BP | October 4, 2024 | A Social Determinants of Health Risk Assessment in the Annual Wellness Visit Policy Update in the Calendar Year 2024 Physician Fee Schedule Final Rule | 13486 |
| R12684BP | June 13, 2024 | Manual Update Pub. 100-02 Medicare Benefit Policy, Chapter 15, Section 110.8 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Benefit Category Determinations | 13651 |
| R12599BP | May 2, 2024 | A Social Determinants of Health Risk Assessment in the Annual Wellness Visit Policy Update in the Calendar Year 2024 Physician Fee | 13486 |
Sections ordered by the date in the revision note printed under each heading.
| Section | Heading | Revision |
|---|---|---|
| 110.8 | DMEPOS Benefit Category Determinations | Rev. 13889, July 30, 2026; effective August 28, 2026 |
| 50.4.4.2 | Immunizations | Rev. 13295, July 25, 2025; effective January 1, 2025 |
| 50.5.1 | Immunosuppressive Drugs | Rev. 13108, April 11, 2025; effective January 1, 2025 |
| 50.5.5 | Hemophilia Clotting Factors | Rev. 13108, April 11, 2025; effective January 1, 2025 |
| 230.3 | Practice of Speech-Language Pathology | Rev. 13051, January 16, 2025; effective April 18, 2025 |
| 280.5.2 | A Social Determinants of Health (SDOH) Risk Assessment in the Annual Wellness Visit (AWV) | Rev. 12865, October 4, 2024; effective January 1, 2024 |
| 300.1 | Beneficiaries Eligible for Coverage and Definition of Diabetes | Rev. 12694, June 21, 2024; effective January 1, 2024 |
| 145 | Lymphedema Compression Treatment Items | Rev. 12532, March 7, 2024; effective January 1, 2024 |
Section index
Every section in the chapter's table of contents, grouped under its top-level heading, with the PDF page where it starts. Open a heading to see its subsections.
10 Supplementary Medical Insurance (SMI) Provisions · p. 7
20 When Part B Expenses Are Incurred · p. 8 · 3 subsections
- Open section 20 in the PDF
- 20.1 Physician Expense for Surgery, Childbirth, and Treatment for Infertility · p. 8
- 20.2 Physician Expense for Allergy Treatment · p. 9
- 20.3 Artificial Limbs, Braces, and Other Custom Made Items Ordered But Not Furnished · p. 9
30 Physician Services · p. 10 · 7 subsections
- Open section 30 in the PDF
- 30.1 Provider-Based Physician Services · p. 14
- 30.2 Teaching Physician Services · p. 15
- 30.3 Interns and Residents · p. 15
- 30.4 Optometrist's Services · p. 16
- 30.5 Chiropractor's Services · p. 17
- 30.6 Indian Health Service (IHS) Physician and Nonphysician Services · p. 18
- 30.6.1 Payment for Medicare Part B Services Furnished by Certain IHS Hospitals and Clinics · p. 18
40 Effect of Beneficiary Agreements Not to Use Medicare Coverage · p. 19 · 39 subsections
- Open section 40 in the PDF
- 40.1 Private Contracts Between Beneficiaries and Physicians/Practitioners · p. 20
- 40.2 General Rules of Private Contracts · p. 20
- 40.3 Effective Date of the Opt-Out Provision · p. 20
- 40.4 Definition of Physician/Practitioner · p. 21
- 40.5 When a Physician or Practitioner Opts Out of Medicare · p. 21
- 40.6 When Payment May be Made to a Beneficiary for Service of an Opt-Out Physician/Practitioner · p. 22
- 40.7 Definition of a Private Contract · p. 22
- 40.8 Requirements of a Private Contract · p. 23
- 40.9 Requirements of the Opt-Out Affidavit · p. 24
- 40.10 Failure to Properly Opt Out · p. 26
- 40.11 Failure to Maintain Opt-Out · p. 26
- 40.12 Actions to Take in Cases of Failure to Maintain Opt-Out · p. 27
- 40.13 Physician/Practitioner Who Has Never Enrolled in Medicare · p. 29
- 40.14 Nonparticipating Physicians or Practitioners Who Opt Out of Medicare · p. 29
- 40.15 Excluded Physicians and Practitioners · p. 29
- 40.16 Relationship Between Opt-Out and Medicare Participation Agreements · p. 30
- 40.17 Participating Physicians and Practitioners · p. 30
- 40.18 Physicians or Practitioners Who Choose to Opt Out of Medicare · p. 31
- 40.19 Opt-Out Relationship to Noncovered Services · p. 31
- 40.20 Maintaining Information on Opt-Out Physicians · p. 31
- 40.21 Informing Medicare Managed Care Plans of the Identity of the Opt-Out Physicians or Practitioners · p. 32
- 40.22 Informing the National Supplier Clearinghouse (NSC) of the Identity of the Opt-Out Physicians or Practitioners · p. 32
- 40.23 Organizations That Furnish Physician or Practitioner Services · p. 32
- 40.24 The Difference Between Advance Beneficiary Notices (ABN) and Private Contracts · p. 32
- 40.25 Private Contracting Rules When Medicare is the Secondary Payer · p. 33
- 40.26 Registration and Identification of Physicians or Practitioners Who Opt Out · p. 33
- 40.27 System Identification · p. 33
- 40.28 Emergency and Urgent Care Situations · p. 33
- 40.29 Definition of Emergency and Urgent Care Situations · p. 35
- 40.30 Denial of Payment to Employers of Opt-Out Physicians and Practitioners · p. 35
- 40.31 Denial of Payment to Beneficiaries and Others · p. 35
- 40.32 Payment for Medically Necessary Services Ordered or Prescribed by an Opt-out physician or Practitioner · p. 35
- 40.33 Mandatory Claims Submission · p. 35
- 40.34 Cancellation of Opt-Out · p. 36
- 40.35 Early Termination of Opt-Out · p. 36
- 40.36 Appeals · p. 36
- 40.37 Application to the Medicare Advantage Program · p. 36
- 40.38 Claims Denial Notices to Opt-Out Physicians and Practitioners · p. 37
- 40.39 Claims Denial Notices to Beneficiaries · p. 37
50 Drugs and Biologicals · p. 38 · 24 subsections
- Open section 50 in the PDF
- 50.1 Definition of Drug or Biological · p. 38
- 50.2 Determining Self-Administration of Drug or Biological · p. 39
- 50.3 Incident-to Requirements · p. 43
- 50.4 Reasonableness and Necessity · p. 44
- 50.4.1 Approved Use of Drug · p. 44
- 50.4.2 Unlabeled Use of Drug · p. 44
- 50.4.3 Examples of Not Reasonable and Necessary · p. 45
- 50.4.4 Payment for Antigens and Immunizations · p. 46
- 50.4.4.1 Antigens · p. 46
- 50.4.4.2 Immunizations · p. 46
- 50.4.5 Off Lable Use of Anti-Cancer Drugs and Biologicals · p. 50
- 50.4.5.1 Process for Amending the List of Compendia for Determination of Medically-Accepted Indications for Off-Label Uses of Drugs and Biologicals in an Anti-Cancer Chemotherapeutic Regimen · p. 53
- 50.4.6 Less Than Effective Drug · p. 55
- 50.4.7 Denial of Medicare Payment for Compounded Drugs Produced in Violation of Federal Food, Drug, and Cosmetic Act · p. 56
- 50.4.8 Process for Amending the List of Compendia for Determination of Medically-Accepted Indications for Off-Label Uses of Drugs and Biologicals in an Anti-Cancer Chemotherapeutic Regimen
- 50.5 Self-Administered Drugs and Biologicals · p. 56
- 50.5.1 Immunosuppressive Drugs · p. 57
- 50.5.2 Erythropoietin (EPO) · p. 58
- 50.5.2.1 Requirements for Medicare Coverage for EPO · p. 58
- 50.5.2.2 Medicare Coverage of Epoetin Alfa (Procrit) for Preoperative Use · p. 60
- 50.5.3 Oral Anti-Cancer Drugs
- 50.5.4 Oral Anti-Nausea (Anti-Emetic) Drugs · p. 61
- 50.5.5 Hemophilia Clotting Factors · p. 62
- 50.6 Coverage of Intravenous Immune Globulin for Treatment of Primary Immune Deficiency Diseases in the Home · p. 62
60 Services and Supplies Furnished Incident To a Physician's/NPP's Professional Service · p. 63 · 5 subsections
- Open section 60 in the PDF
- 60.1 Incident To Physician's Professional Services · p. 64
- 60.2 Services of Nonphysician Personnel Furnished Incident To Physician's Services · p. 65
- 60.3 Incident To Physician'sServices in Clinic · p. 66
- 60.4 Services Incident to a Physician's Service to Homebound Patients Under General Physician Supervision · p. 67
- 60.4.1 Definition of Homebound Patient Under the Medicare Home Health (HH) Benefit · p. 69
70 Sleep Disorder Clinics · p. 70
80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests · p. 72 · 29 subsections
- Open section 80 in the PDF
- 80.1 Clinical Laboratory Services · p. 74
- 80.1.1 Certification Changes · p. 74
- 80.1.2 A/B MAC (B) Contacts With Independent Clinical Laboratories · p. 75
- 80.1.3 Independent Laboratory Service to a Patient in the Patient's Home or an Institution · p. 75
- 80.2 Psychological and Neuropsychological Tests · p. 76
- 80.3 Audiology Services · p. 78
- 80.3.1 Definition of Qualified Audiologist · p. 83
- 80.4 Coverage of Portable X-Ray Services Not Under the Direct Supervision of a Physician · p. 84
- 80.4.1 Diagnostic X-Ray Tests · p. 84
- 80.4.2 Applicability of Health and Safety Standards · p. 84
- 80.4.3 Scope of Portable X-Ray Benefit · p. 84
- 80.4.4 Exclusions From Coverage as Portable X-Ray Services · p. 85
- 80.4.5 Electrocardiograms · p. 85
- 80.5 Bone Mass Measurements (BMMs) · p. 85
- 80.5.1 Background · p. 85
- 80.5.2 Authority · p. 86
- 80.5.3 Definition · p. 86
- 80.5.4 Conditions for Coverage · p. 86
- 80.5.5 Frequency Standards · p. 86
- 80.5.6 Beneficiaries Who May be Covered · p. 87
- 80.5.7 Noncovered BMMs · p. 87
- 80.5.8 Claims Processing · p. 87
- 80.5.9 National Coverage Determinations (NCDs)
- 80.6 Requirements for Ordering and Following Orders for Diagnostic Tests · p. 88
- 80.6.1 Definitions · p. 88
- 80.6.2 Interpreting Physician Determines a Different Diagnostic Test is Appropriate · p. 89
- 80.6.3 Rules for Testing Facility to Furnish Additional Tests · p. 89
- 80.6.4 Rules for Testing Facility Interpreting Physician to Furnish Different or Additional Tests · p. 89
- 80.6.5 Surgical/Cytopathology Exception · p. 90
90 X-Ray, Radium, and Radioactive Isotope Therapy · p. 91
100 Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations · p. 91
110 Durable Medical Equipment - General · p. 92 · 8 subsections
- Open section 110 in the PDF
- 110.1 Definition of Durable Medical Equipment · p. 93
- 110.2 Repairs, Maintenance, Replacement, and Delivery · p. 96
- 110.3 Coverage of Supplies and Accessories · p. 98
- 110.4 Miscellaneous Issues Included in the Coverage of Equipment · p. 98
- 110.5 Incurred Expense Dates for Durable Medical Equipment · p. 99
- 110.6 Determining Months for Which Periodic Payments May Be Made for Equipment Used in an Institution · p. 99
- 110.7 No Payment for Purchased Equipment Delivered Outside the United States or Before Beneficiary's Coverage Began · p. 99
- 110.8 DMEPOS Benefit Category Determinations · p. 100
120 Prosthetic Devices · p. 117
130 Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes · p. 120
140 Therapeutic Shoes for Individuals with Diabetes · p. 121
145 Lymphedema Compression Treatment Items · p. 125
150 Dental Services · p. 127 · 1 subsections
- Open section 150 in the PDF
- 150.1 Treatment of Temporomandibular Joint (TMJ) Syndrome · p. 129
160 Clinical Psychologist Services · p. 130
170 Clinical Social Worker (CSW) Services · p. 132
180 Nurse-Midwife (CNM) Services · p. 133
190 Physician Assistant (PA) Services · p. 136
200 Nurse Practitioner (NP) Services · p. 139
210 Clinical Nurse Specialist (CNS) Services · p. 142
220 Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance · p. 145 · 8 subsections
- Open section 220 in the PDF
- 220.1 Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services · p. 155
- 220.1.1 Care of a Physician/Nonphysician Practitioner (NPP) · p. 156
- 220.1.2 Plans of Care for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services
- 220.1.3 Certification and Recertification of Need for Treatment and Therapy Plans of Care · p. 161
- 220.1.4 Requirement That Services Be Furnished on an Outpatient Basis · p. 165
- 220.2 Reasonable and Necessary Outpatient Rehabilitation Therapy Services · p. 166
- 220.3 Documentation Requirements for Therapy Services · p. 173
- 220.4 Functional Reporting · p. 188
230 Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology · p. 191 · 6 subsections
- Open section 230 in the PDF
- 230.1 Practice of Physical Therapy · p. 193
- 230.2 Practice of Occupational Therapy · p. 196
- 230.3 Practice of Speech-Language Pathology · p. 202
- 230.4 Services Furnished by a Therapist in Private Practice (TPP) · p. 206
- 230.5 Physical Therapy, Occupational Therapy and Speech-Language Pathology Services Provided Incident to the Services of Physicians and Nonphysician Practitioners (NPP) · p. 208
- 230.6 Therapy Services Furnished Under Arrangements With Providers and Clinics · p. 210
231 Pulmonary Rehabilitation (PR) Program Services Effective For Dates of Service On Or After January 1, 2024 · p. 214
232 Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Services Effective For Dates of Service On Or After January 1, 2024 · p. 216
240 Chiropractic Services - General · p. 219 · 6 subsections
- Open section 240 in the PDF
- 240.1 Coverage of Chiropractic Services · p. 220
- 240.1.1 Manual Manipulation · p. 220
- 240.1.2 Subluxation May Be Demonstrated by X-Ray or Physician's Exam · p. 221
- 240.1.3 Necessity for Treatment · p. 224
- 240.1.4 Location of Subluxation · p. 226
- 240.1.5 Treatment Parameters · p. 227
250 Medical and Other Health Services Furnished to Inpatients of Hospitals and Skilled Nursing Facilities · p. 228
260 Ambulatory Surgical Center Services · p. 229 · 8 subsections
- Open section 260 in the PDF
- 260.1 Definition of Ambulatory Surgical Center (ASC) · p. 229
- 260.2 Ambulatory Surgical Center Services · p. 230
- 260.3 Services Furnished in ASCs Which are Not ASC Facility Services · p. 233
- 260.4 Coverage of Services in ASCs, Which are Not ASC Services · p. 234
- 260.5 List of Covered Ambulatory Surgical Center Procedures · p. 235
- 260.5.1 Nature and Applicability of ASC List · p. 236
- 260.5.2 Nomenclature and Organization of the List · p. 236
- 260.5.3 Rebundling of CPT Codes · p. 237
270 Telehealth Services · p. 237
280 Preventive and Screening Services · p. 237 · 12 subsections
- Open section 280 in the PDF
- 280.1 Glaucoma Screening
- 280.2 Colorectal Cancer Screening · p. 240
- 280.2.1 Covered Services and HCPCS Codes · p. 240
- 280.2.2 Coverage Criteria · p. 241
- 280.2.3 Determining Whether or Not the Beneficiary is at High Risk for Developing Colorectal Cancer · p. 246
- 280.2.4 Determining Frequency Standards · p. 249
- 280.2.5 Noncovered Services · p. 250
- 280.3 Screening Mammography · p. 250
- 280.4 Screening Pap Smears · p. 251
- 280.5 Annual Wellness Visit (AWV) Providing Personalized Prevention Plan Services (PPPS) · p. 253
- 280.5.1 Advance Care Planning (ACP) Furnished as an Optional Element with an Annual Wellness Visit (AWV) upon Agreement with the Patient · p. 258
- 280.5.2 A Social Determinants of Health (SDOH) Risk Assessment in the Annual Wellness Visit (AWV) · p. 258
290 Foot Care · p. 259
300 Diabetes Self-Management Training Services · p. 265 · 7 subsections
- Open section 300 in the PDF
- 300.1 Beneficiaries Eligible for Coverage and Definition of Diabetes · p. 266
- 300.2 Certified Providers
- 300.3 Frequency of Training · p. 268
- 300.4 Coverage Requirements for Individual Training · p. 269
- 300.4.1 Incident -To Provision · p. 270
- 300.5 Payment for DSMT · p. 270
- 300.5.1 Special Claims Processing Instructions A/B MACs (A) · p. 270
310 Kidney Disease Patient Education Services · p. 271 · 5 subsections
- Open section 310 in the PDF
- 310.1 Beneficiaries Eligible for Coverage · p. 272
- 310.2 Qualified Person · p. 272
- 310.3 Limitations for Coverage · p. 273
- 310.4 Standards for Content · p. 273
- 310.5 Outcomes Assessment · p. 275
320 Home Infusion Therapy Services · p. 275 · 18 subsections
- Open section 320 in the PDF
- 320.1 General Requirements for Payment of Home Infusion Therapy Services · p. 276
- 320.2 Home Infusion Therapy Services Benefit is Separate from DME Benefit · p. 276
- 320.3 Qualified Home Infusion Therapy Suppliers · p. 277
- 320.4 Patient Eligibility for Home Infusion Therapy · p. 277
- 320.4.1 Home Infusion Therapy Services for Homebound Patients · p. 278
- 320.5 Plan of Care Requirements · p. 279
- 320.5.1 Notification of Available Infusion Therapy Options · p. 279
- 320.5.2 Plan of Care Periodic Review and Provider Coordination · p. 280
- 320.6 Professional Services, Including Nursing Services, for Home Infusion Therapy · p. 281
- 320.6.1 Home Infusion Therapy Services Training and Education · p. 282
- 320.6.2 Remote Monitoring and Monitoring Services · p. 284
- 320.7 Home Infusion Therapy Drugs · p. 284
- 320.7.1 Determining Qualifying Home Infusion Drugs · p. 285
- 320.8 Determining Qualifying Home Infusion Drugs · p. 286
- 320.8.1 Home Infusion Drug Payment Categories · p. 286
- 320.8.2 Infusion Drug Administration Calendar Day and Unit of Single Payment · p. 287
- 320.8.3 Initial Visits and Subsequent Visits for Home Infusion Therapy Services · p. 288
- 320.9 Medical Review · p. 288
330 Marriage and Family Therapist (MFT) Services · p. 288
340 Mental Health Counselor (MHC) Services · p. 291
Using this chapter in a denial or appeal
Start with the remittance. The claim adjustment reason code says what happened to the line, the remark code narrows it, and the group code says who is liable. Match that to the section of the chapter that sets the rule, then read the section in the official PDF rather than a summary: the wording that matters, such as a time limit, a modifier requirement or a documentation element, is usually a single sentence. Check the revision note under the section heading, because a rule that changed after the date of service may not apply to the claim, and an effective date earlier than the issue date can make a new rule reach back.
When the chapter supports the claim, cite it precisely in the redetermination request: the publication number, chapter, section and revision. When it does not, the fix is usually a corrected claim or better documentation rather than an appeal, and a coding or format rejection is corrected and resubmitted because it carries no appeal rights. Manual instructions bind the Medicare Administrative Contractor, so they settle most first-level disputes; at the hearing level, administrative law judges give them substantial deference without being bound by them. If the issue turns on whether a service is covered at all, read the matching Benefit Policy Manual chapter and any national coverage determination or local coverage determination as well, because coverage and billing rules are written in different places.
How QuickIntell works with Benefit Policy Manual chapter 15
QuickAuth coordinates requirement checks, documentation, submission and status tracking with human review, so the coverage conditions in this chapter are looked at before the service. QuickRCM handles claim readiness and the coverage denials that follow.
Frequently asked questions: chapter 15
Where are the incident-to rules in the Medicare manuals?
Chapter 15 section 60 of the Medicare Benefit Policy Manual (Pub. 100-02). Sections 60.1 to 60.3 set the conditions, including direct supervision in the office setting, and 60.4 covers services to homebound patients under general supervision.
What does Medicare Benefit Policy Manual chapter 15 cover?
Covered medical and other health services under Part B: physician and nonphysician practitioner services, incident-to services, drugs, diagnostic tests, DME and prosthetics, outpatient therapy, chiropractic care, rehabilitation programs, preventive services, home infusion therapy and more.
Does chapter 15 say who must order a diagnostic test?
Yes. Section 80.6 requires diagnostic tests to be ordered by the physician or practitioner who is treating the beneficiary and who uses the results in the beneficiary's management, with limited exceptions for testing facility physicians.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.
- Medicare Benefit Policy Manual, Chapter 15: Covered Medical and Other Health ServicesVersion Rev. 13889, issued 2026-07-30 · effective 2026-08-28 · file bp102c15.pdfSHA-256 b34540f5453915a2…
- Medicare Benefit Policy Manual (Pub. 100-02)Version 17 chapter PDFs; newest revision Rev. 13889 (chapter 15), issued 2026-07-30 · effective 2026-09-27 · file 100-02-benefit-policy-manual/*.pdf (17 chapters; SHA-256 of their sha256sum listing)SHA-256 be35772e4f9f80b4…
Disclaimer
This guide summarizes a CMS manual chapter in our own words for billing teams; section headings and transmittal subjects are quoted from the chapter PDF. The chapter itself is the authority, and it changes by transmittal. Not legal, clinical or billing advice.
Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.