Reimbursement Resources

AAPA Resources (pdf)



Medicare- Maine

Overview

Medicare is a government-administered program providing health insurance to 43 million Americans. The Centers for Medicare and Medicaid Services (CMS) implements laws and establishes policies affecting Medicare and contracts with health care professionals to process Medicare claims.

Medicare rules require that services provided by physician assistants (PAs) be reimbursed at 85 percent of the physician fee schedule unless specific billing exceptions discussed below (“incident to” and “shared visits billing”) apply. To receive reimbursement, PAs must bill Medicare at the full physician rate. A PA must enroll in the Medicare program by submitting the 855I form, and use his or her National Provider Identifier (NPI) number to alert the carrier to implement the 15 percent discount. It is also required for Medicare providers to enroll via the PECOS system.

NPI numbers can be obtained on-line at https://nppes.cms.hhs.gov/NPPES/Welcome.do . After completing the NPI application, you should receive an NPI number within 2 weeks. If after 2 weeks you have not received your number contact the NPI Enumerator at: 1-800-465-3203 or 1-800-692-2326 (TTY).

The Medicare 855I form can be found at http://www.cms.hhs.gov/cmsforms/downloads/cms855i.pdf. This form should be submitted to your local Medicare Administrative Contractor (MAC). ). You can also submit enrollment requests on-line at (recommended).

Services provided by PAs are reimbursable by Medicare when provided in offices or clinics, nursing facilities, hospitals, and ambulatory surgical centers. Medicare pays PAs for nearly all types of medical and surgical services as allowed by state law. Medicare Benefit Policy Manual, Chapter 15, Section 190.Covered services include, but are not limited to, high-level evaluation and management services, consultations, initial hospital histories and physicals, mental health services, diagnostic tests, telemedicine services, and ordering durable medical equipment.

Medicare Administrative Contractor (MAC)

Maine has been assigned to MAC Jurisdiction 14, served by the National Heritage Insurance Corporation (NHIC). Local policies and coverage determinations can be found at the NHIC website. Updates are posted regularly, and you can sign up to receive e-mail alerts on the website as well.

Note: NHIC has posted a “suggestion” regarding incident-to billing in their July 2010 Billing Guide. (See pg 15.)

“NHIC suggests the physician or practitioner reviews the progress and co-signs the charts. When services are billed incident to a MD, it is as if the MD personally performed the services. When a MD personally performs a service, the MD signs the chart. The MD is personally responsible for all incident to services rendered to the patient, so co-signing the chart confirms his understanding of his responsibility & liability for the billed services. This also confirms that the MD is actively involved in the patient care and is aware of the patient's status at all times.”

“Incident to” Billing in an Office or Clinic Setting “Incident to” is a Medicare billing provision that allows reimbursement for services delivered by PAs at 100 percent of the physician fee schedule, provided that all “incident to” criteria are met. “Incident to” billing only applies in the office or clinic. It requires that:

  1. The physician must have personally treated the patient on his or her initial visit for the particular medical problem and established the diagnosis and treatment plan. The physician must also diagnose and establish a treatment plan for any new medical conditions that may arise.
  2. The physician is within the suite of offices when the PA renders the service.
  3. The service is within the PA’s scope of practice and in accordance with state law.

If all criteria are met, the PA’s services are billable under the supervising physician’s Medicare number with payment at 100 percent of the fee schedule. If the criteria are not met, the PA can still perform the service; however, the PA’s services must be billed to Medicare under the PA’s own number for reimbursement at 85 percent of the physician fee schedule.

There must be subsequent services performed by the physician of a frequency that reflects his or her continuing and active participation in patient management and course of treatment.

A Medicare reference regarding “incident-to” can be found in the Medicare Benefit Policy Manual, Chapter 15, Section 60.1, and in Transmittal 1764.
Again, be aware of the NHIC recommendations regarding documentation for incident to billing.


FAQ
Will a PA Be Reimbursed When He or She Sees a New Medicare Patient?
Yes, as long as visits with new patients are allowed by state law, a PA may see a new Medicare patient. This visit should be billed using the PA’s Medicare number for reimbursement at 85 percent of the physician fee schedule.
May I Bill “Incident to” for a Visit if My Supervising Physician Is Next Door at the Hospital?
No. In order to qualify for “incident to” billing, the supervising physician must be within the suite of offices.
May I Bill “Incident to” in a Hospital or a Nursing Facility?
No. “Incident to” can be applied only in a physician’s office or clinic.

Again, be aware of the documentation requirements suggested by NHIC in their July 2010 Billing Guide (See pg 15.)

“NHIC suggests the physician or practitioner reviews the progress and co-signs the charts. When services are billed incident to a MD, it is as if the MD personally performed the services. When a MD personally performs a service, the MD signs the chart. The MD is personally responsible for all incident to services rendered to the patient, so co-signing the chart confirms his understanding of his responsibility & liability for the billed services. This also confirms that the MD is actively involved in the patient care and is aware of the patient's status at all times.”


Shared Visits

A Shared Visit applies to E/M services in which both the physician and the PA participate, allowing the combined service to be billed under the physician’s NPI, with reimbursement at 100% of the Physician Fee Schedule.1 The shared visit concept does not apply to procedures or critical care services or nursing home visits. The PA and physician must be employed by the same entity. Shared visits can be applied to initial and subsequent hospital visits, as well as visits in the Emergency Dept. In the office/clinic , a shared visit only applies to an established patient.

“When an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed “incident to” if the requirements for “incident to” are met and the patient is an established patient.”

Reference:
Medicare Claims Processing Manual, Chapter 12, Section 30.6.1 (B)
Medicare Transmittal 1776

The physician must provide some face-to-face time with the patient and must document those E/M services and findings in the chart. Simply co-signing the PA’s note is not sufficient. The physician’s documentation must clearly indicate what portions of the E/M services were provided by the physician.

The patient must be seen by the PA and the physician on the same calendar day. However, this does not mean at the same time. A shared visit example from the Medicare manual states:

“If the NPP (non-physician practitioner) sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service.”