A. Clinical Social Worker Defined Section 1861(hh) of the Act defines a
“clinical social worker” as an individual who:
• Possesses a master’s or doctor’s degree in social work;
• Has performed at least two years of supervised clinical social work; and
• Is licensed or certified as a clinical social worker by the State in which the services are performed; or
• In the case of an individual in a State that does not provide for licensure or certification, has completed at least 2 years or 3,000 hours of post master’s degree supervised clinical social work practice under the supervision of a master’s level social worker in an appropriate setting such as a hospital, SNF, or clinic.
B. Clinical Social Worker Services Defined
Section 1861(hh)(2) of the Act defines “clinical social worker services” as those services that the CSW is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) of the State in which such services are performed for the diagnosis and treatment of mental illnesses. Services furnished to an inpatient of a hospital or an inpatient of a SNF that the SNF is required to provide as a requirement for participation are not included. The services that are covered are those that are otherwise covered if furnished by a physician or as incident to a physician’s professional service.
C. Covered Services
Coverage is limited to the services a CSW is legally authorized to perform in accordance with State law (or State regulatory mechanism established by State law). The services of a CSW may be covered under Part B if they are:
• The type of services that are otherwise covered if furnished by a physician, or as incident to a physician’s service. (See §30 for a description of physicians’ services and §70 of Pub 100-1, the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, for the definition of a physician.);
• Performed by a person who meets the definition of a CSW (See subsection A.); and
• Not otherwise excluded from coverage.
Carriers should become familiar with the State law or regulatory mechanism governing a CSW’s scope of practice in their service area.
D. Noncovered Services
Services of a CSW are not covered when furnished to inpatients of a hospital or to inpatients of a SNF if the services furnished in the SNF are those that the SNF is required to furnish as a condition of participation in Medicare. In addition, CSW services are not covered if they are otherwise excluded from Medicare coverage even though a CSW is authorized by State law to perform them. For example, the Medicare law excludes from coverage services that are not “reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.”
