Medicare Mid-Level Provider 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.

FAQ 1. What is a Non-Physician Practitioner (NPP) and how does the definition apply in the ED?  What is the appropriate terminology for NPs and PAs in the ED?

An NPP in the ED is defined by Medicare as either a nurse practitioner (NP) or a physician assistant (PA).  Of note, there is no agreed upon terminology that encompasses NPs and PAs in the ED.  In grouping these providers, the DEA uses the term "midlevels" while the Federal agencies use a variety of references.  For the sake of this FAQ, NPs and PAs will be referred to as advanced practice providers (APPs), as this seems to be gaining favor.  However, it is acknowledged that, as per 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]"

FAQ 2. When an APP 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 APP or the emergency physician?

When an emergency department E/M is shared between a physician and an APP from the same group practice and the physician provides and documents any "face-to-face" portion of the E/M encounter with the patient, the service may be billed under either the physician's or the APP's NPI number. However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by discussing the case with the APP or reviewing the patient's medical record) then the service may only be billed under the APP'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 APPs 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.

FAQ 3.  What documentation is necessary for the emergency physician to indicate a shared E/M service?

The medical record must clearly identify both the APP and the emergency physician who shared in rendering the service.  The emergency physician documentation should be linked to the APP documentation of the shared service, and affirmatively state one or more elements of the encounter.  This element may be an element of history, physical examination, or medical decision-making.

In a shared E/M situation, both parties must document the work they performed.  A generic attestation of "I have seen and evaluated this patient and agree with the PA notes" or a notation of "seen and agreed" or "agree with above" would not qualify the service as a shared visit.

FAQ 4.  Can an APP perform Critical Care?

Critical care services may be provided by qualified APPs and reported for payment under the APP'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 APP practices and provides the service(s).

FAQ 5.  Can the APP Critical Care time and the emergency physician Critical Care time be added together and reported as a shared service?

A critical care code for the specific time period (either 99291 or 99292) cannot be reported as a split/shared E/M service.  Each critical care code shall reflect the evaluation, treatment and management of a patient by an individual physician or qualified non-physician practitioner and shall not be representative of a combined service between a physician and a qualified APP.

Although different practitioner types (i.e., physician or APP) cannot combine their respective CC times to qualify for a given CC code (either 99291 or 99292), once the same category of practitioners' CC time qualifies for a CC code, that CC code can be reported as part of the practice group's total CC coding.

FAQ 6.  When an APP performs an independent service must a physician also sign the chart, or can the service be billed with only the APP's signature?

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

FAQ 7. What is "incident to" and is it applicable in the ED?

"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 practitioners 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".

FAQ 8.  Can the emergency physician bill for a procedure that is performed by an APP on a Medicare patient?

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

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

FAQ 9.  Can APPs provide services to non-Medicare patients?

Yes, but be sure to consider state regulations regarding APP scope of practice. All 50 states now give PA's prescribing authority, and they have enacted fairly detailed statutes and regulations that define physician assistants, 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 PA's 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.

Unlike Medicare, which mandates coverage of services provided by PA's, each state determines whether PA's are eligible providers under its respective program.  All states and the District of Columbia cover PA's 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 PA's to identify themselves as a provider of service.  In some states, medical services provided by PA's are billed under the physician's name, while in other states, PA's use a modifier code to identify their services. In the majority of states (37), the Medicaid programs enroll or credential PAs and require them to bill with their own identifier as rendering provider. 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.

FAQ 10.  Will our APPs need a NPI number?

Yes. If the APP will be providing services to Medicare patients, and you want to bill for such services Medicare mandates that all APPs 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 APPs.

FAQ 11. What is a modifier and how does it affect physician assistant or nurse practitioner billing?

Modifiers are two characters (alpha or numeric) codes that can be appended to CPT codes to "modify" the service. In the past, Medicare required modifiers such as "AN" or "AS" to identify services involving a physician extender. Medicare carriers have abandoned the use of modifiers for physician extenders and now require physician assistants and nurse practitioners to obtain and use NPI's to identify their services.

FAQ 12.  Can an APP act as a scribe for the physician?

Yes, but be careful. A scribe records the findings of a physician. If the APP 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.

FAQ 13. To what extent, if any, will Medicare rules apply when APPs treat patients who are in Medicare managed care plans?

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

FAQ 14. What services are APPs allowed to provide in the ED?

Medicare will pay for ED E/M services for specific non-physician practitioners, i.e., nurse practitioner (NP) and physician assistant (PA). The services provided must be medically necessary and the service must be within the scope of practice for a non-physician practitioner in the State in which he/she practices. According to Transmittal 1548, which was released by CMS in 2008, qualified APPs 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. View the full transmittal on the CMS site.

FAQ 15.  Where can I get more information on mid-level providers?

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

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, CAE, Reimbursement Director, ACEP at (972) 550-0911, Ext. 3233 or dmckenzie@acep.org.

Updated 03/03/2016

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