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Physician Assistants and Nurse Practitioners FAQ

This document reflects changes to the Medicare Carriers Manual by the Centers for Medicare and Medicaid Services (CMS) pursuant to Transmittal 1776 implemented on October 25, 2002 (http://www.cms.hhs.gov/transmittals/downloads/R1776B3.pdf).

A significant change in documentation requirements occurs when an emergency department E/M is shared between a physician and a nurse practitioner (NP) or physician assistant (PA) from the same group practice.

  • What is a PA or NP and how does the definition apply in the ED? What is the appropriate terminology for PAs and NPs in the ED?

    Recommendations
    Answer

    Medicare defines both a nurse practitioner (NP) or a physician assistant (PA) as an ED advanced practice provider.  Of note, there is no agreed upon terminology that encompasses PAs and NPs in the ED.  In grouping these providers, the DEA uses the term "mid-levels" while the Federal agencies use a variety of references. CMS uses the term Non-Physician Provider (NPP). For the sake of this FAQ, PAs and NPs will be referred to as their individual training certification and no longer grouped as advanced practice providers (APPs) as had been written in previous versions.  This acknowledgment is supported, by the American Academy of Physician Assistants (AAPA) Policy #HP-3100.1.3, "the AAPA believes whenever possible, PAs should be referred to as "physician assistants" and not combined with other providers in inclusive non-specific terms such as "midlevel practitioner", "advanced practice clinician", or "advanced practice provider". [Adopted 2008, reaffirmed 2013]"

    Answer

    Medicare defines both a nurse practitioner (NP) or a physician assistant (PA) as an ED advanced practice provider.  Of note, there is no agreed upon terminology that encompasses PAs and NPs in the ED.  In grouping these providers, the DEA uses the term "mid-levels" while the Federal agencies use a variety of references. CMS uses the term Non-Physician Provider (NPP). For the sake of this FAQ, PAs and NPs will be referred to as their individual training certification and no longer grouped as advanced practice providers (APPs) as had been written in previous versions.  This acknowledgment is supported, by the American Academy of Physician Assistants (AAPA) Policy #HP-3100.1.3, "the AAPA believes whenever possible, PAs should be referred to as "physician assistants" and not combined with other providers in inclusive non-specific terms such as "midlevel practitioner", "advanced practice clinician", or "advanced practice provider". [Adopted 2008, reaffirmed 2013]"

  • What is “Split/Shared” and how does it govern charging for a visit when both the physician and PA or NP are involved?

    Recommendations
    Answer

    One must first understand the concept of a “Split/Shared Visit” when considering how to differentiate billing between the APP and physician.  Starting in 2022, CMS has new language for split/ shared services to reflect a change in medical services towards a more team-based approach to care. CMS defines a split/shared service as a visit performed both by a physician and non-physician provider (NPP). CMS believes that when a visit is shared between a physician and a non-physician provider in the same group there would be a close coordination and an element of collaboration in providing care to the beneficiary. CMS proposes to permit the physician or NPP to bill for split or shared visits and believes this approach is consistent with CPT E/M guidelines for split or shared visits. Beginning in 2022, CMS policy is that the documentation in the medical record must identify the two individual practitioners who performed the visit. The individual who performed the substantive portion will bill for the visit and must sign and date the medical record.

    When an emergency department E/M is shared between a physician and a PA or NP from the same group practice and the physician provides the substantive portion of the E/M encounter with the patient, then the service may be billed under either the physician's or the PA's or NP’s UPIN/PIN number.  If the physician does not provide the substantive portion of the encounter even if the physician participated in the service by reviewing the patient’s medical record, then the service may only be billed under the PA's or NP’s UPIN/PIN.  In this scenario payment will be made at 85 percent of the Medicare physician fee schedule.

    Answer

    One must first understand the concept of a “Split/Shared Visit” when considering how to differentiate billing between the APP and physician.  Starting in 2022, CMS has new language for split/ shared services to reflect a change in medical services towards a more team-based approach to care. CMS defines a split/shared service as a visit performed both by a physician and non-physician provider (NPP). CMS believes that when a visit is shared between a physician and a non-physician provider in the same group there would be a close coordination and an element of collaboration in providing care to the beneficiary. CMS proposes to permit the physician or NPP to bill for split or shared visits and believes this approach is consistent with CPT E/M guidelines for split or shared visits. Beginning in 2022, CMS policy is that the documentation in the medical record must identify the two individual practitioners who performed the visit. The individual who performed the substantive portion will bill for the visit and must sign and date the medical record.

    When an emergency department E/M is shared between a physician and a PA or NP from the same group practice and the physician provides the substantive portion of the E/M encounter with the patient, then the service may be billed under either the physician's or the PA's or NP’s UPIN/PIN number.  If the physician does not provide the substantive portion of the encounter even if the physician participated in the service by reviewing the patient’s medical record, then the service may only be billed under the PA's or NP’s UPIN/PIN.  In this scenario payment will be made at 85 percent of the Medicare physician fee schedule.

  • When a PA or NP and an emergency physician provide care to the same Medicare patient, how is the record evaluated to determine if the E/M service should be assigned to the PA or NP or the emergency physician?

    Recommendations
    Answer

    When an emergency department E/M is shared between a physician and a PA or NP from the same group practice and the physician provides a substantive portion of the E/M visit,  the service may be billed under either the physician's or the PA’s or NP's NPI number.

    The medical record should indicate that the physician performed a substantive portion of the E/M visit. For 2022, the substantive portion will be defined as one of the three key components (history, exam, or MDM) or more than half of the total time spent by the physician and the PA or NP performing the shared visit. Of note time is not a descriptive element for ED E/M codes.

    However, if the physician does not provide the substantive portion of the encounter, then the service may only be billed under the PA's or NP’s NPI and payment will be made at 85% of the Medicare physician fee schedule.

    Because there are many varied circumstances under which physicians and PAs or NPs interact and the stipulation for "same group practice" is open to interpretation, you are advised to contact your local carrier for final instructions on billing when shared services arise. In addition, some non-Medicare payers still require the physician to perform a face-to-face interaction with the patient, and some do not recognize PAs or NPs so the service may have to be reported using the physician’s UPIN.

    Answer

    When an emergency department E/M is shared between a physician and a PA or NP from the same group practice and the physician provides a substantive portion of the E/M visit,  the service may be billed under either the physician's or the PA’s or NP's NPI number.

    The medical record should indicate that the physician performed a substantive portion of the E/M visit. For 2022, the substantive portion will be defined as one of the three key components (history, exam, or MDM) or more than half of the total time spent by the physician and the PA or NP performing the shared visit. Of note time is not a descriptive element for ED E/M codes.

    However, if the physician does not provide the substantive portion of the encounter, then the service may only be billed under the PA's or NP’s NPI and payment will be made at 85% of the Medicare physician fee schedule.

    Because there are many varied circumstances under which physicians and PAs or NPs interact and the stipulation for "same group practice" is open to interpretation, you are advised to contact your local carrier for final instructions on billing when shared services arise. In addition, some non-Medicare payers still require the physician to perform a face-to-face interaction with the patient, and some do not recognize PAs or NPs so the service may have to be reported using the physician’s UPIN.

  • What documentation is necessary for the emergency physician to indicate a shared E/M service?

    Recommendations
    Answer

    The medical record must clearly identify both the PA or NP and the emergency physician who shared in rendering the service.

    Starting in 2022 the physician must sign and date the medical record by putting their name on the bill. This affirms the individual performed the substantive portion of the service. However, you were advised to seek guidance from your local Medicare Administrative Contractor (MAC) to make sure the regional MAC doesn't have additional rules to identify the substantive portion.

    In the 2021 Physician Fee Schedule, CMS reduced the burden of documentation by the supervising physician by implementing a broadened general principle that applies to:

    1. All physicians
    2. Physician Assistants (PAs)
    3. Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs); Certified Nurse-Midwives (CNMs), and Certified Registered Nurse Anesthetists (CRNAs), each of whom are recognized as Advanced Practice Registered Nurses (APRNs).

    This principle allows physicians to review and verify (sign/date) documentation in the medical record without having to re-document notes that are already included in the medical record. 

    This provision allows PA and APRN students or other members of the medical team, as allowed to make notes in a patient’s medical record, as reviewed and verified by physicians, PAs, and APRNs.

    Reference:  https://www.cms.gov/files/document/mm11560

    Answer

    The medical record must clearly identify both the PA or NP and the emergency physician who shared in rendering the service.

    Starting in 2022 the physician must sign and date the medical record by putting their name on the bill. This affirms the individual performed the substantive portion of the service. However, you were advised to seek guidance from your local Medicare Administrative Contractor (MAC) to make sure the regional MAC doesn't have additional rules to identify the substantive portion.

    In the 2021 Physician Fee Schedule, CMS reduced the burden of documentation by the supervising physician by implementing a broadened general principle that applies to:

    1. All physicians
    2. Physician Assistants (PAs)
    3. Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs); Certified Nurse-Midwives (CNMs), and Certified Registered Nurse Anesthetists (CRNAs), each of whom are recognized as Advanced Practice Registered Nurses (APRNs).

    This principle allows physicians to review and verify (sign/date) documentation in the medical record without having to re-document notes that are already included in the medical record. 

    This provision allows PA and APRN students or other members of the medical team, as allowed to make notes in a patient’s medical record, as reviewed and verified by physicians, PAs, and APRNs.

    Reference:  https://www.cms.gov/files/document/mm11560

  • Can a PA or NP perform Critical Care?

    Recommendations
    Answer

    Critical care services may be provided by qualified PAs or NPs and reported for payment under the PA's or NP’s National Provider Identifier (NPI) when the services meet the definition and requirements of critical care services.  The provision of critical care services must be within the scope of practice and licensure requirements for the State in which the qualified PA or NP practices and provides the service(s). As critical care is a timed service, the individual (PA, NP or MD) who provided the service consistent with the critical care descriptor (first 30-74 minutes) would bill for the service. (See FAQ 6).

    Answer

    Critical care services may be provided by qualified PAs or NPs and reported for payment under the PA's or NP’s National Provider Identifier (NPI) when the services meet the definition and requirements of critical care services.  The provision of critical care services must be within the scope of practice and licensure requirements for the State in which the qualified PA or NP practices and provides the service(s). As critical care is a timed service, the individual (PA, NP or MD) who provided the service consistent with the critical care descriptor (first 30-74 minutes) would bill for the service. (See FAQ 6).

  • Can the PA or NP Critical Care time and the emergency physician Critical Care time be added together and reported as a shared service?

    Recommendations
    Answer

    In 2022, CMS has new language for a shared critical care visit between a PA or NP and the emergency physician allowing them to aggregate the combined time. The provider who furnished the majority of the time is the one who should report the critical care codes applicable.

    Answer

    In 2022, CMS has new language for a shared critical care visit between a PA or NP and the emergency physician allowing them to aggregate the combined time. The provider who furnished the majority of the time is the one who should report the critical care codes applicable.

  • When an PA or NP performs an independent service must a physician also sign the chart, or can the service be billed with only the PA's or NP’s signature?

    Recommendations
    Answer

    The physician's requirement to provide supervision of the PA or NP is governed by individual state licensing regulations and hospital medical staff policies and procedures. Additionally, different payers might interpret the definition of supervision differently.

    Answer

    The physician's requirement to provide supervision of the PA or NP is governed by individual state licensing regulations and hospital medical staff policies and procedures. Additionally, different payers might interpret the definition of supervision differently.

  • What is "incident to" and is it applicable in the ED?

    Recommendations
    Answer

    "Incident to" is a Medicare reimbursement policy, whereby, under certain circumstances, the physician can bill and be paid for services that were provided by non-physician providers who are employed by the physician.

    Services covered by Medicare "incident to" are those services furnished in a physician office. It is not applicable in the hospital setting--either inpatient or outpatient --and as such it is not applicable in the emergency department. In other words, Medicare does not allow "incident to" billing in the emergency department.

    *Please note that a "shared/split E/M service" (see FAQ 2 above) differs from "incident to."

    Answer

    "Incident to" is a Medicare reimbursement policy, whereby, under certain circumstances, the physician can bill and be paid for services that were provided by non-physician providers who are employed by the physician.

    Services covered by Medicare "incident to" are those services furnished in a physician office. It is not applicable in the hospital setting--either inpatient or outpatient --and as such it is not applicable in the emergency department. In other words, Medicare does not allow "incident to" billing in the emergency department.

    *Please note that a "shared/split E/M service" (see FAQ 2 above) differs from "incident to."

  • Can the emergency physician bill for a procedure that is performed by a PA or NP on a Medicare patient?

    Recommendations
    Answer

    The shared service concept only applies to E/M services. Procedures and interpretations performed by the APP must be billed using the PA's or NP’s NPI number. The shared service rules only apply to E/M services and "incident to" does not apply in the ED.

    Any physician, PA or NP authorized to bill Medicare services will be paid by the carrier at the appropriate physician fee schedule amount based on the rendering NPI.

    Answer

    The shared service concept only applies to E/M services. Procedures and interpretations performed by the APP must be billed using the PA's or NP’s NPI number. The shared service rules only apply to E/M services and "incident to" does not apply in the ED.

    Any physician, PA or NP authorized to bill Medicare services will be paid by the carrier at the appropriate physician fee schedule amount based on the rendering NPI.

  • Can PAs or NPs provide services to non-Medicare patients?

    Recommendations
    Answer

    Yes, but be sure to consider state regulations regarding PA’s or NP’s scope of practice. All 50 states now give PA’s or NP’s prescribing authority, and they have enacted detailed statutes and regulations that define PAs and NPs, describe their scope of practice, discuss supervision, designate the agency that will administer the law, set application and renewal criteria, and establish disciplinary measures for specified violations of the law. The actual language in the scope of practice section of the regulations is generally broad allowing PAs or NPs to perform those services within the scope of the supervising physician if delegated by the physician, and within the education and training of the PA or NP.

    Unlike Medicare, which mandates coverage of services provided by PAs or NPs, each state determines whether PAs or NPs are eligible providers under its respective program.  All states and the District of Columbia cover PAs or NPs in the Medicaid fee-for-service or managed care plans at the same or lower rate as that paid to physicians. There are differences, however, in how states ask PAs or NPs to identify themselves as a provider of service.  In some states, medical services provided by PAs or NPs are billed under the physician's name, while in other states, PAs or NPs use a modifier code to identify their services. Finally, some state Medicaid programs will limit procedure reimbursement even when the state itself recognizes the procedure as within the APP's scope of service. Check with your state Medicaid carrier for specific policies and procedures.

    Answer

    Yes, but be sure to consider state regulations regarding PA’s or NP’s scope of practice. All 50 states now give PA’s or NP’s prescribing authority, and they have enacted detailed statutes and regulations that define PAs and NPs, describe their scope of practice, discuss supervision, designate the agency that will administer the law, set application and renewal criteria, and establish disciplinary measures for specified violations of the law. The actual language in the scope of practice section of the regulations is generally broad allowing PAs or NPs to perform those services within the scope of the supervising physician if delegated by the physician, and within the education and training of the PA or NP.

    Unlike Medicare, which mandates coverage of services provided by PAs or NPs, each state determines whether PAs or NPs are eligible providers under its respective program.  All states and the District of Columbia cover PAs or NPs in the Medicaid fee-for-service or managed care plans at the same or lower rate as that paid to physicians. There are differences, however, in how states ask PAs or NPs to identify themselves as a provider of service.  In some states, medical services provided by PAs or NPs are billed under the physician's name, while in other states, PAs or NPs use a modifier code to identify their services. Finally, some state Medicaid programs will limit procedure reimbursement even when the state itself recognizes the procedure as within the APP's scope of service. Check with your state Medicaid carrier for specific policies and procedures.

  • Will our PAs and NPs need a NPI number?

    Recommendations
    Answer

    Yes. If the PA or NP will be providing services to Medicare patients, and you want to bill for such services, Medicare mandates that all PAs or NPs have a NPI number. It would be wise to do a compliance audit with your company or billing entity to assure that proper NPI numbers are on the CMS1500 for services provided by PAs or NPs.

    Answer

    Yes. If the PA or NP will be providing services to Medicare patients, and you want to bill for such services, Medicare mandates that all PAs or NPs have a NPI number. It would be wise to do a compliance audit with your company or billing entity to assure that proper NPI numbers are on the CMS1500 for services provided by PAs or NPs.

  • What is a modifier and how does it affect PA or NP billing?

    Recommendations
    Answer

    In 2022 CMS requires modifier “FS” (Split [or shared] E/M visit) be appended to a split/shared visit performed in a facility setting and split or shared critical are visits.

    Answer

    In 2022 CMS requires modifier “FS” (Split [or shared] E/M visit) be appended to a split/shared visit performed in a facility setting and split or shared critical are visits.

  • Can a PA or NP act as a scribe for the physician?

    Recommendations
    Answer

    Yes, but be careful. A scribe records the findings of a physician. If the PA or NP independently obtains the history and performs a physical exam, a third-party payer might not consider this a scribe function but rather an independent service component by a healthcare provider, hence subject to the payer's relevant payment policies.

    Answer

    Yes, but be careful. A scribe records the findings of a physician. If the PA or NP independently obtains the history and performs a physical exam, a third-party payer might not consider this a scribe function but rather an independent service component by a healthcare provider, hence subject to the payer's relevant payment policies.

  • To what extent, if any, will Medicare rules apply when PAs and NPs treat patients who are in Medicare managed care plans?

    Recommendations
    Answer

    General CMS rules should still apply, although you should check with the specific managed care plan to verify any policies in question.

    Answer

    General CMS rules should still apply, although you should check with the specific managed care plan to verify any policies in question.

  • What services are PAs and NPs allowed to provide in the ED?

    Recommendations
    Answer

    Medicare will pay for ED E/M services provided by PAs or NPs. The services provided must be medically necessary and the service must be within the scope of practice for a PA or NP in the State in which he/she practices. According to Transmittal 1548, which was released by CMS in 2008, qualified PAs or NPs may provide critical care services (and report for payment under their National Provider Identifier (NPI), when these services meet the critical care services definition and requirements.  See:  https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1548OTN.pdf

    Answer

    Medicare will pay for ED E/M services provided by PAs or NPs. The services provided must be medically necessary and the service must be within the scope of practice for a PA or NP in the State in which he/she practices. According to Transmittal 1548, which was released by CMS in 2008, qualified PAs or NPs may provide critical care services (and report for payment under their National Provider Identifier (NPI), when these services meet the critical care services definition and requirements.  See:  https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1548OTN.pdf

  • Where can I get more information on PAs and NPs?

    Recommendations
    Answer

    The American Academy of Physician Assistants (AAPA) can be reached at the address below or at their web site http://www.aapa.org. This web site contains a wealth of information. Be sure to access the government and practice issues section and click on reimbursement for additional documentation

    The American Academy of Physician Assistants (AAPA)
    2318 Mill Road, Suite 1300
    Alexandria, Virginia 22314-1552
    Phone: 703-836-2272
    Fax: 703-684-1924

    www.aapa.org   

    The American College of Nurse Practitioners (ACNP)
    AANP National Administrative Office
    PO Box 12846 
    Austin, Texas 78711
    Phone: 512-442-4262
    Fax: 512-442-6469 
    www.aanp.org

    Answer

    The American Academy of Physician Assistants (AAPA) can be reached at the address below or at their web site http://www.aapa.org. This web site contains a wealth of information. Be sure to access the government and practice issues section and click on reimbursement for additional documentation

    The American Academy of Physician Assistants (AAPA)
    2318 Mill Road, Suite 1300
    Alexandria, Virginia 22314-1552
    Phone: 703-836-2272
    Fax: 703-684-1924

    www.aapa.org   

    The American College of Nurse Practitioners (ACNP)
    AANP National Administrative Office
    PO Box 12846 
    Austin, Texas 78711
    Phone: 512-442-4262
    Fax: 512-442-6469 
    www.aanp.org

Updated December 2021

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.

The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer.

For information about this FAQ/Pearl, or to provide feedback, please contact David A. McKenzie, ACEP Reimbursement Director at (469) 499-0133 or dmckenzie@acep.org.

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