Reimbursement

Medical and surgical services delivered by PAs are covered by Medicare, Medicaid, and nearly all private payers. It is important to verify each payer’s coverage policies for PAs. Each payer has its own guidelines regarding service coverage and payment.

  Third-Party Reimbursement: Issue Brief [PDF]

This issue brief by the AAPA gives an overview of PA reimbursement through third-party payers.

 Antitrust Implications of Negotiating with Third-Party Payers [PDF]

Learn about antitrust laws related to payment for services prepared by the AAPA.

 Resources


Medicare pays for medical and surgical services provided by PAs at 85 percent of the physician fee schedule. This rate applies to all practice settings, including hospitals (inpatient, outpatient and emergency departments), nursing facilities, homes, offices and clinics. It also applies to first assisting at surgery. Medicare had a myriad of policies and regulations that must be followed in order to avoid allegations of fraud and abuse.

The following articles detail policy for billing for services provided by PAs. Access this document.  If you have any questions please call the OAPA office and we will get your questions answered.

 

Medicare Benefit Policy Manual: Physician Assistant Services


This document is a direct citation from the Medicare Manual authorizing coverage of professional services provided by PAs. Additional information may be obtained through Medicare or the OAPA office. 

Medicare Preventive Services 

PAs may provide Medicare Preventive Services, including the "Welcome to Medicare" exam and the “Annual Wellness Visit.” There are many rules, requirements, limitations and screening schedules for these services.

Effective January 2011, Medicare expanded coverage to allow payment for an annual wellness visit (AWV) (subject to certain eligibility and other limitations). Part B deductibles and Medicare coinsurance will not apply to the AWV.

The implementation instructions, including definition of services and new billing codes, can be found in the CMS transmittal, Annual Wellness Visit, Including Personalized Preventive Plan Services

"Incident-to" Billing  

"Incident-to" is a Medicare provision that allows for services provided by a PA in the office to be billed under the NPI of the physician with reimbursement at 100%.

“Incident to” is a Medicare billing provision that allows PAs to bill Medicare under the physician’s NPI if Medicare’s strict criteria are met. Those criteria are: 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; Physician is on site, within the suite of offices; and Services are within the PA’s state law scope of practice.


Shared Visit Billing  

Shared visit billing is a Medicare provision that allows for services provided in the hospital by both the PA and the physician to be billed under the NPI of the physician with reimbursement at 100%.

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.

Medicare Enrollment  

Physician assistants must apply first for an NPI number, then enroll in Medicare via the PECOS system. This document contains detailed instructions.

For a physician assistant to be an eligible Medicare provider, he or she must meet the following requirements:

Have graduated from a physician assistant education program that is accredited by the Accreditation Review Commission on Education for the Physician Assistantm or, prior to 2001, either by the Committee on Allied Health Education and Accreditation or the Commission on Accreditation of Allied Health Education Programs; or Have passed the national certification examination administered by the National Commission on Certification of Physician Assistants (NCCPA); and be licensed or certified by any states in which he or she wishes to practice as a physician assistant. 

If a PA meets the above criteria he or she may obtain a NPI and enroll with Medicare.

Private Payer Policy for PAs

Practices must ascertain the payment policy and claims submission instructions for services provided by PAs from each payer with whom they contract. Policies vary by company.  The OAPA is willing to help you find different insurance policies.

First Assisting at Surgery 

PAs first assisting at surgery are reimbursed by Medicare at 85 percent of the first-assisting fee paid to a physician (16 percent), or 13.6 percent. PAs cannot act as primary surgeons, but they are eligible for reimbursement for first assisting in any procedure where a physician would receive such a reimbursement. PAs are also covered when performing minor surgical procedures. PAs should bill for their services at the full physician fee schedule. The use of the PA’s NPI number and the “AS” surgical assistant billing modifier will indicate to the Medicare carrier to implement the appropriate discount.

For more information, see the Medicare Claims Processing Manual, Chapter 12, Section 110.3 .

Home Health Services

There are new home health requirements for a face-to-face visit, which may be provided by a PA.

As a condition forpayment 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 Skilled Nursing Facility/Inpatient Rehab

Physicians managing patient care in nursing facilities and skilled nursing facilities may delegate visits to PAs. In skilled nursing facilities, services assigned to a physician (such as the initial comprehensive visit) must be performed by a physician and not delegated to a PA. If allowed by state law, Medicare allows PAs practicing in nursing facilities to provide services that are designated as physician services, as long as they are not employed by the facility. Additionally, Medicare regulations dictate that nursing home patients be seen at least once every 30 days for the first 90 days of care and every 60 days thereafter. Of these visits, a physician and a PA may alternate visits and a PA may perform any necessary scheduled visits without disrupting the established alternating visit pattern. [42CFR, § 483.40]

Medicare Preventive Services

PAs may provide the "Welcome to Medicare" visit, annual wellness visit, and other preventive services.

E-Prescribing

PAs are eligible for the Medicare e-prescribing incentive payments, but are also subject to the penalties if not successfully prescribing.

Electronic Health Record Incentive Program

PAs are not eligible for the Medicare EHR incentive program. PAs in limited circumstances can be eligible for the Medicaid EHR incentive program.

Calculating PA Productivity

This collection of information highlights the considerations and challenges associated with calculating PA Productivity.