Transcript Medicare “Incident to” - Michigan Academy of Physician Assistants

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Reimbursement Primer for PAs
James A. Kilmark, PA-C
• Physician Assistant in Emergency Medicine
• Co-Lead PA – St. Joseph Mercy Hospital
Emergency Department, Ann Arbor MI
• Past President – Michigan Academy of
Physician Assistants
• Michigan Academy of Physician Assistants
Chairperson – Reimbursement Committee
• Governor Appointed Member – Michigan
Board of Osteopathic Medicine and Surgery
Disclaimer: This Presentation is provided for informational purposes only and does
not constitute legal or payment advice. The ultimate responsibility for statutory and
regulatory compliance, as well as the proper submission of claims, rests entirely upon
the provider of services.
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Learning Objectives
• Review of Michigan Law regarding PA scope of practice
• Discuss Medicare Reimbursement for services provided by PAs
– Basic concepts for Practices / hospitals to receive
payment from Medicare for PA services
– Incident to
– Shared visits
– Procedures and critical care
– Diagnostic testing
– Home Care Certification
– DME and upcoming changes
• Michigan Medicaid – Enrollment of PAs as providers
• Blue Cross Blue Sheild of Michigan
– Direct versus Indirect Billing
– Physical Therapy Orders
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Supervision and Scope of Practice
The boundaries of a PAs scope of practice
are determined by four parameters:
1. Delegation by a Supervising Physician
2. PAs Education and Experience
3. State Law
4. Facility Policy
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Michigan Public Health Code
“Practice as a Physician Assistant” means the practice
of medicine, osteopathic medicine and surgery, and
podiatric medicine and surgery and is defined as a
health profession subfield (MCL 333.17001, 333.17008).
"Practice of medicine" means the diagnosis, treatment,
prevention, cure, or relieving of a human disease,
ailment, defect, complaint, or other physical or mental
condition, by attendance, advice, device, diagnostic
test, or other means, or offering, undertaking,
attempting to do, or holding oneself out as able to do,
any of these acts (MCL333.17001).
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Scope of Practice
Physicians may delegate to PAs those medical duties that
are within the physician’s scope of practice and the PAs
training and experience and are allowed by law
(MCL 333.17049(2), 333.17076).
Under Michigan Health Code, the things that must not be
delegated to a PA include:
Tests to determine refractive state of human eye or
determine lens prescriptions (MCL 333.17014)
Termination of a pregnancy including prescribing the
morning after pill (MCL 333.17015, MCL 750.15, R333.108a)
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Definition of Supervision
• In MI: “Supervision” requires:
• Continuous availability of direct
communication in person or by radio,
telephone, or telecommunication
• Regularly scheduled review of the practice of
the supervised individual, to provide
consultation to the supervised individual, to
review records, and to further educate the
supervised individual in the performance of
the individual's functions.
MCL333.16109
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Supervising Physician
Responsibilities
• Must verify the PAs credentials, evaluate
performance, and monitor the practice and
provision of medical care (MCL333.17409(1)).
• A physician group may designate one or more
physicians to fulfill these requirements.
• Must also keep on file at the practice site a
permanent written record of the physician’s
name/license number and the name/license
number of each PA supervised by the physician.
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Supervising Physician
Responsibilities
• (MCL 333.17048) - “…a physician who is a sole practitioner
or practices in a group of physicians and treats patients on
an outpatient basis shall not supervise more than 4
physician’s assistants.
• If a physician…supervises physician’s assistants at more than
1 practice site, the physician shall not supervise more than 2
physician’s assistants by a method other than the physician’s
actual physical presence at the site.”
• “A physician who is employed by, or under contract or
subcontract to, or has privileges at a health facility or
agency licensed under article 17 or a state correctional
facility may supervise more than 4 physician’s assistants (at
these facilities).”
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Physical Therapy (PT)
• Requires the prescription of an individual
licensed under part 166, 170, 175, 180 (MCL
333.17820).
–
–
–
–
Dentists
Allopathic/Osteopathic Physicians
Podiatrists
PAs
• OT & Speech typically follow same rules
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Medicare Enrollment
• Before enrolling in the Medicare Program you
must have a National Provider identifier (NPI) to
apply
https://npiregistry.cms.hhs.gov
• To enroll with a Regional Medicare Provider
(Michigan’s Regional Medicare provider is WPS)
you must enroll in PECOS which stands for the
Provider Enrollment Chain and Ownership System
http://www.cms.gov/Medicare/Provider-EnrollmentandCertification/MedicareProviderSupEnroll/Internetbased
PECOS.html
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Medicare Payment
Qualifications for PAs
PAs may furnish services billed under all levels of
CPT evaluation and management codes, and
diagnostic tests if furnished under the general
supervision of a physician. **
The physician supervisor (or physician designee)
need not be physically present with the PA when a
service is being furnished to a patient and may be
contacted by telephone, if necessary, unless State
law or regulations require otherwise.
extracted from Medicare Benefit Policy Manual
Chapter 15, Section 190
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Medicare Payment
Qualifications for PAs
To furnish covered PA services, the PA must meet the conditions
as follows:
1. Have graduated from a physician assistant educational
program that is accredited by the Accreditation Review
Commission on Education for the Physician Assistant (its
predecessor agencies, the Commission on Accreditation of
Allied Health Education Programs (CAAHEP) and the
Committee on Allied Health Education and Accreditation
(CAHEA); or
2. Have passed the national certification examination that is
administered by the National Commission on Certification of
Physician Assistants (NCCPA); and
3. Be licensed by the State to practice as a physician assistant.
Excerpt from Medicare Policy Manual: Chapter 15 §190
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Medicare Payment
Covered Services
Coverage is limited to the services a PA is legally authorized to
perform in accordance with State law (or State regulatory mechanism
provided by State law).
Generally the services of a PA may be covered under Medicare Part B,
if all of the following requirements are met:
• They are the type that are considered physician’s services if
furnished by a doctor of medicine or osteopathy (MD/DO);
• They are performed by a person who meets all the PA
qualifications,
• They are performed under the general supervision of an MD/DO;
• The PA is legally authorized to perform the services in the state in
which they are performed; and
• They are not otherwise precluded from coverage because of one of
the statutoryExcerpt
exclusions.
from Medicare Policy Manual: Chapter 15 §190
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Supervision Under Medicare
Physician Supervision
The PA’s physician supervisor (or a physician designated by the
supervising physician or employer as provided under State law
or regulations) is primarily responsible for the overall direction
and management of the PA’s professional activities and for
assuring that the services provided are medically appropriate
for the patient.
The physician supervisor (or physician designee) need not be
physically present with the PA when a service is being furnished
to a patient and may be contacted by telephone, if necessary,
unless State law or regulations require otherwise.
Excerpt from Medicare Policy Manual: Chapter 15 §190
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Medicare - Employing Relationship
Payment for the services of a PA may be made only to the actual
qualified employer of the PA that is eligible to enroll in the Medicare
program under existing Medicare provider/supplier categories. If the
employer of the PA is a professional corporation or other duly
qualified legal entity (such as a limited liability company or a limited
liability partnership, properly formed, authorized and licensed under
State laws and regulations, that permits PA ownership in such
corporation nor entity as a stockholder or member that corporation or
entity as the employer may bill for PA services even if a PA is a
stockholder or officer of the entity, as long as the entity is entitled to
enroll as a “provider of services” or a supplier of services in the
Medicare program. Physician Assistants may not otherwise organize
or incorporate and bill for their services directly to the Medicare
program, including as, but not limited to sole proprietorships or
general partnerships. Accordingly, a qualified employer is not a group
of PAs that incorporate to bill for their services. Leasing agencies and
staffing companies do not qualify under the Medicare program as
“providers of services” or suppliers of services.
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Medicare
PAs may perform (as allowed by state
law):
• All E/M codes (including high levels)
• Critical care & observation codes
• Initial hospital admit & pre-surgical H&Ps
• diagnostic tests**/procedures
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Medicare
Medicare will reimburse for services
provided to Medicare beneficiaries
provided by PAs in all areas / settings:
At 85% of the physician fee schedule
Why is this important?
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Medicare “Incident to”
“Incident to” is a Medicare billing provision that allows PAs to bill Medicare
under the physician’s NPI number, if Medicare’s strict criteria for “incidentto” billing are met:
•
Services are provided in a physician’s office or physician’s clinic;
•
Physician sees Medicare patient on initial visit, establishes a diagnosis and
treatment plan. PA sees patient on follow up visit;
•
For established Medicare patients with a new problem, the physician sees
the patient first for the new problem, establishes a diagnosis and
treatment plan, PA sees patient on follow up visit;
•
a Physician is on site, within the suite of offices, when the patient is seen
by the PA;
•
Services are within the PA’s state law scope of practice; and
•
the PA represents a direct financial expense to the physician billing (W-2
or leased employee, or independent contractor).
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Medicare “Incident to”
The physician must continue to see the patient at a
frequency that reflects ongoing management of the
patient’s care. If all of the above criteria (previous slide)
are met, you may bill Medicare under the physician’s NPI
with reimbursement at 100%.
If any of the first 4 bulleted criteria are not met, bill
Medicare under the PA’s NPI with reimbursement at 85%.
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Medicare “Incident to”
Patient care example:
A Medicare patient has been previously treated by the
physician and diagnosed with hypertension. On a
subsequent visit to the physician's office, a PA saw the
patient and evaluated his or her hypertension within the
plan of care established by the physician on the initial
visit. The physician or another physician within the group
was on-site within the suite of offices at the time the PA
saw and treated the patient.
The practice may bill the office visit, "incident to,"
under the NPI of the physician on-site, with
reimbursement at 100%.
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Medicare “Incident to”
What Happens in the above scenario if the PA needs to change the
medication dose?
It Depends…..
The Medicare Carrier for Michigan (WPS) is educating that if the PA
does something as simple as changing the medication dosing then this
would go outside that physicians established plan of care and thus
would not allow for “incident to” billing
AAPA Billing experts feel that this is an over interpretation but would
suggest that if the med dosing needs to be changed that the PA
document physician involvement in the medication dosing change and
that the physician see the patient on the following visit.
MAPA is working with AAPA to obtain a clarification to this scenario….
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Medicare “Incident to”
PAs may see new Medicare patients, see established
Medicare patients with new problems, and may see
Medicare patients under state law guidelines for
supervision; the claim must then be submitted under the
PA’s NPI.
Reimbursement at will be at 85% of the Physician Fee
Schedule.
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Medicare “Incident to”
Remember!
“Incident to” is a Medicare Provision this provision
does not necessarily apply to Private Payers
“Incident to” applies to the outpatient physician
office only! There are separate provisions for
hospital based PA practice.
Should your office use “incident to”?
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Medicare “Shared Service”
Shared Visit billing is a Medicare provision that applies to an
evaluation and management (E/M) service 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.
• 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.
• 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.
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Medicare “Shared Service”
“Shared Services” apply to Hospital
Inpatient / Hospital Outpatient and
Emergency Department Settings.
“Incident to” does not apply in these
settings
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Medicare “Shared Service”
To properly document a “Shared Service” the
Physician must have a face to face encounter
with the patient on the same calendar day as
the PA
The Physician must document a portion of the
evaluation and management (E&M) encounter.
“Seen and Agree”, “I agree with the PAs plan”
does not meet the level for “shared service”
billing.
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Medicare Shared Visit – Key Points
Hospital inpt/outpt or ED
Services performed on same calendar day
Common employment
E/M services, but not critical care or
procedures
• Physician delivers face-to-face portion of
E/M service
• Clear documentation on medical record of
physician’s professional service
•
•
•
•
Medicare & First Assist at Surgery
• Medicare covers PAs for first assisting at
surgery at 85 percent of the physician fee
schedule (85% of the 16% physician first
assistant rate) or 13.6 percent of the
primary surgeon's fee for the surgery
• PAs can provide the same range of first
assistant services as physicians. A claim for
first assisting at surgery should be
submitted with the PA's NPI number (or PIN)
and the AS modifier to the surgical code.
Surgical 1st Assist - Medicare &
Teaching Hospital Rules
• If a teaching hospital has an approved, accredited surgical
training program related to the surgery being performed and
has a qualified resident available to perform the service, no
reimbursement is made for a licensed health care
professional first assisting.
• If, however, a primary surgeon has an across-the-board
policy of never allowing residents to act as first assistants, or
in trauma cases, or if the surgeon believes that the resident
is not the best individual to perform the service of if a
qualified resident is not available, Medicare will reimburse
for a first assist provided by a PA.
[Medicare Claims Processing Manual Chapter 12, Section 100.1.7]
Surgical 1st Assist - Medicare &
Teaching Hospital Rules
•
In the above cases, claims should be accompanied by an
explanation that the first assist was medically necessary and
that no qualified resident was available to first assist at that
time. Medicare requires the following attestation in the
operative report:
“I understand that section 1842(b)(7)(D) of the Social Security Act
generally prohibits Medicare physician fee schedule payment for
the services of assistants at surgery in teaching hospitals when
qualified residents are available to furnish such services. I certify
that the services for which payment is claimed were medically
necessary and that no qualified resident was available to perform
the services. I further understand that these services are subject
to post- payment review by the Medicare carrier.”
[Medicare Claims Processing Manual Chapter 12, Section 100.1.7]
Surgical 1st Assist – Medicare &
Teaching Hospital Rules

Any restrictions on billing apply only to first assisting
at surgery, not to other services delivered in the
hospital

Resident billing rules do not apply to PAs

PAs are statutorily authorized as a benefit category to
bill Medicare, residents typically are not
[Medicare Carriers Manual Section 15106]
Medicare – Supervision of
Diagnostic Tests
The billing rules for diagnostic tests require that Medicare providers
meet a specified level of physician supervision to bill for certain
diagnostic tests. The supervision guideline establishes three levels of
supervision with the following definitions:
• General supervision means the procedure is furnished under the
physician's overall direction and control, but the physician’s
presence is not required during the performance of the procedure;
• Direct supervision in the office setting means the physician must
be present in the office suite and immediately available to furnish
assistance and direction throughout the performance of the
procedure. It does not mean that the physician must be present in
the room; and
• Personal supervision means a physician must be in attendance in
the room during the performance of the procedure.
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Medicare – Supervision of
Diagnostic Tests
• PAs may order & perform diagnostic tests
consistent with state law scope of
practice (42 CFR 410.32) under general
supervision
• PAs may not supervise other personnel
performing tests that require direct or
personal supervision
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Medicare – Supervision of
Diagnostic Tests
• Q: Stress Tests?
– 93015, 93016, 93017, 93018
– Personnel require DIRECT supervision from
physician (exception: PAs performing test =
general supervision)
– PAs may perform stress testing under general
supervision, but cannot supervise other
personnel performing the stress test since for
non-PA personnel direct supervision is
required
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Home Health Care and
the Face to Face Encounter
As a condition for payment for home health services,
the Affordable Care Act mandates that, prior to
certifying a patient's eligibility for the home health
benefit, the certifying physician must document that he
or she, or an allowed non-physician practitioner (NPP),
has had a face-to-face encounter with the patient. An
allowed NPP is defined as a PA, NP, CNM, or CNS.
Home Health Care and
the Face to Face Encounter
Key elements of the new rule include:
• Documentation of the face-to-face encounters must be
present on certifications for patients with starts of care on and
after January 1, 2011.
• As part of the certification form itself, or as an addendum to it,
the physician must document:
1. when the physician or allowed NPP saw the patient, and
2. how the patient’s clinical condition as seen during that encounter
supports the patient’s homebound status and need for skilled services.
• The face-to-face encounter must occur within the 90 days
prior to the start of home health care, or within the 30 days
after the start of care.
Home Health Care and
the Face to Face Encounter
• In many cases, home health agencies will not initiate home
care services without the certification form documenting the
above requirements and signed by a physician.
• While the PA may complete the face-to-face encounter, the
physician must "certify" that the visit occurred by signing the
completed form.
Details can be found in CMS Transmittal 139
Medicare and DME
Since 2001 PAs have been able to write/order/sign
the certificate of medical necessity for Medicare
DME (exception for diabetic shoes) with no direct
involvement from the physician. That has not
changed.
Provision in the ACA required that Medicare
increase the oversight on ordering DME.
CMS proposal is for a face-to-face visit and a
physician co-signature on 167 high dollar or high
volume DME items.
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Medicare and DME
• AAPA argued that this policy would disrupt
access to care with no increase in
accountability for DME.
• Rule scheduled to go into effect July1 2013,
but was delayed.
• Rules then scheduled to be effective
October1, 2013 but was delayed until
“sometime” in 2014.
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Medicaid - Fee for Service
Bulletin Number: MSA 12-42
Issued: August 31, 2012
Subject: Medicaid Enrollment of Physician Assistants and Nurse Practitioners
Effective: October 1, 2012
Programs Affected: Medicaid
Purpose:
This bulletin provides information describing the mandatory enrollment of
licensed Physician Assistants (PAs) and Nurse Practitioners (NPs) who render,
order, or bill for covered services to Medicaid beneficiaries. Starting October
1, 2012, these providers are to begin enrolling in the Community Health
Automated Medicaid Processing System (CHAMPS). As of January 1, 2013, PAs
and NPs will no longer bill for rendered services under their
delegating/supervising physician’s National Provider Identifier (NPI) and must
be uniquely identified on all claims.
http://www.michigan.gov/documents/mdch/MSA_12-42_396734_7.pdf
Medicaid - Fee for Service
Provider Enrollment of Physician Assistants
PAs must enroll with an Individual (Type 1) NPI number as a
Rendering/Servicing-Only provider. As a Rendering/Service-Only
provider, services are strictly provided under the delegation and
supervision of a physician licensed under part 170, part 175 or part
180 of Michigan Public Act 368 of 1978, as amended.
Upon enrollment, PAs are also required to affiliate themselves with
the billing NPI of their respective delegating/supervising physicians.
Individual PAs are not eligible for direct Medicaid reimbursement.
Direct payment for services rendered by a PA will be issued to the PA’s
affiliated delegating/supervising physician, group or billing provider
NPI. The NPI of the PA’s delegating/supervising physician will also be
required on claim submissions for reimbursement.
http://www.michigan.gov/documents/mdch/MSA_12-42_396734_7.pdf
Medicaid - Managed Care
• Vast majority of all Medicaid
beneficiaries are served by Medicaid
Managed Care Plans
• Most Medicaid Managed Care Plans
credential PAs as Primary Care Providers
• Reimbursement for services provided by
the PA is paid to the PA’s employer at
the physician’s fee schedule rate
BCBSM supervision requirements from Oct.
2000 “The Record”
BCBS requirements are based on the Michigan Public Health Code,
1. The PA must be licensed to render the services.
2. A licensed physician must supervise the PA.
3. The supervising physician and the PA must be available for direct and
continuous communication either in person or by some other
communication, such as telephone.
4. The supervising physician must be available on a regularly scheduled basis
to review the PA’s practice, provide consultation to the PA, review records
and further educate the PA in the performance of his or her functions.
5. The supervising physician must provide the PA with predetermined
procedures and drug protocols.
6. Review of the PAs records and co signature of the supervising physician is
required.
Blue Cross Blue Shield Of Michigan
• Register with BCBSM and obtain an
individual PA PIN or add a PA to a group.
• Call BCBSM’s Provider Enrollment and
Data Management department at 800822-2761
• bcbsm.com/provider/enrollment*
*www.bcbsm.com/provider/enrollment/physicians_physician_assis
tant.shtml
Blue Cross Blue Shield Of Michigan
• Allows Direct or Indirect Billing for services
provided by a PA
• Direct Billing refers to the billing of services
under the provider identification number of the
PA practitioner who performed the service
Source: BCBSM The Record April 2008 - page 21
Blue Cross Blue Shield Of Michigan
• If the PA provides any level of service that is
provided without fulfilling one of the three
“indirect billing” scenarios the bill is
submitted using the PAs license number and
85% of the Physician’s Fee schedule will be
paid to the practice.
• Bill services performed by the physician
assistant by reporting the billing physician's
or group's PIN in field 33b and the physician
assistant's license number in field 24J on the
CMS-1500.
Source: BCBSM The Record April 2008 - page 21
Blue Cross Blue Shield Of Michigan
• Indirect Billing describes billing for
services rendered by the PA under the
PIN of the supervising physician
Source: BCBSM The Record April 2008 - page 21
Blue Cross Blue Shield Of Michigan
“Indirect Criteria”
• Any service where the physician delivers
any component of the service
• Services for which the physician has
provided specific clinical direction to the
Non physician Practitioner prior to or
during the service
• Services for which the PA has presented
pertinent clinical findings and obtained
approval of evaluation and management by
the physician prior to the end of the day
following the service
Source: BCBSM The Record April 2008 - page 21
Blue Cross Blue Shield Of Michigan
• Report the PIN of the billing physician in
field 24J, Rendering Provider ID #, on
the CMS-1500 claim.
• Do not include the physician assistant's
license number on these claims.
Source: BCBSM The Record April 2008 - page 21
BCBSM Exclusions for “Direct”
billing
• Physician assistant, certified nurse
practitioner group exclusion chart updated
• Changes Since the January 2011 issue of The
Record
• Group numbers Excluded for PA and CNP
reimbursement
• Chrysler group #82300 and 82500 “Non-Retiree
Choice” retirees and TRW71393 All groups
BCBSM Exclusions for “Direct”
billing
• Not payable for “Direct Billing” services
by PAs
BUT…
• Payable when services are performed in
collaboration with the PAs supervising
physician using the “Indirect Billing”
Method
Source: BCBSM The Record February 2009 - page 3
BCBSM Update on Reimbursement for
Hospital Employed PAs
• BCBSM has indicated that a hospital will not
be reimbursed for services provided by
hospital employed PAs if the PAs salary is
part of the negotiated hospital payments.
• THE QUESTION! ARE HOSPITALS INCLUDING
PAS IN THE FINANCIAL REPORTS SUPPLIED TO
BCBSM IN THE PAYMENT NEGOTIATIONS?
BCBSM Update on Reimbursement for
Hospital Employed PAs
• MAPA met directly with BCBSM regarding
the issue of reimbursement for PA services
by hospital employed PAs and they did
indicate that hospitals may individually
negotiate payment for hospital employed
PAs if the PAs salaries are not included in
the negotiations for payment to the
hospital.
Physical Therapy for BCBSM
Patients
MEDICAL AFFAIRS RESPONSE
Good afternoon Mr. Kilmark,
This is a follow-up to the Blue Cross Blue Shield of Michigan Physician Assistant physical
therapy referral policy. Blue Cross Blue Shield of Michigan will continue to allow the
Physician Assistants to order physical therapy without an MD/DO order. We plan to update
our Certificates to accommodate this in early 2015 when the certificates become available
for updating. As an FYI – the Michigan Physical Therapy Association was advised of this
decision as well.
We appreciate your willingness to work with us as we strive to make doing business with Blue
Cross Blue Shield of Michigan a valued experience.
Thank you for your time and patience regarding this matter.
Latricia Solomon
Senior Analyst - Medical Affairs
JUMP Support/Liaison
Mail code 509C
313 448-3274
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Private Payers
 Most private payers cover services
delivered by PAs/NPs
 Many payers require billing for NPPs to
be submitted under the physician’s
name and/or provider number or the
hospital’s tax ID
 Not necessarily the same as Medicare’s
“incident to” policy
Private Payers
 It is not fraud to bill under the
physician/hospital if authorized by the
payer
 It is a mistake to assume that all payers
follow the same billing rules
 Must have specific policies from payers
in your region
Questions?