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Reimbursement Primer for PAs

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2 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.

3 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

4 Supervision and Scope of Practice
The boundaries of a PAs scope of practice are determined by four parameters: Delegation by a Supervising Physician PAs Education and Experience State Law Facility Policy

5 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 , ). "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 (MCL ).

6 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 (2), ). 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 ) Termination of a pregnancy including prescribing the morning after pill (MCL , MCL , R a)

7 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. MCL

8 Supervising Physician Responsibilities
Must verify the PAs credentials, evaluate performance, and monitor the practice and provision of medical care (MCL (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.

9 Supervising Physician Responsibilities
(MCL ) - “…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).”

10 Physical Therapy (PT) OT & Speech typically follow same rules
Requires the prescription of an individual licensed under part 166, 170, 175, 180 (MCL ). Dentists Allopathic/Osteopathic Physicians Podiatrists PAs OT & Speech typically follow same rules


12 Medicare Enrollment Before enrolling in the Medicare Program you must have a National Provider identifier (NPI) to apply 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

13 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

14 Medicare Payment Qualifications for PAs
To furnish covered PA services, the PA must meet the conditions as follows: 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 Have passed the national certification examination that is administered by the National Commission on Certification of Physician Assistants (NCCPA); and Be licensed by the State to practice as a physician assistant. Excerpt from Medicare Policy Manual: Chapter 15 §190

15 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 statutory exclusions. Excerpt from Medicare Policy Manual: Chapter 15 §190

16 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

17 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.

18 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

19 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?

20 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 “incident- to” 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).

21 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%.

22 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%.

23 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….

24 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.

25 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”?

26 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.

27 Medicare “Shared Service”
“Shared Services” apply to Hospital Inpatient / Hospital Outpatient and Emergency Department Settings. “Incident to” does not apply in these settings

28 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.

29 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

30 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.

31 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 ]

32 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 ]

33 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]

34 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.

35 Medicare – Supervision of Diagnostic Tests
PAs may order & perform diagnostic tests consistent with state law scope of practice (42 CFR ) under general supervision PAs may not supervise other personnel performing tests that require direct or personal supervision

36 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

37 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.

38 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.

39 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

40 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.

41 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.


43 Medicaid - Fee for Service
Bulletin Number: MSA 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. 43

44 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 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. 44

45 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


47 BCBSM supervision requirements from Oct. 2000 “The Record”
BCBS requirements are based on the Michigan Public Health Code, The PA must be licensed to render the services. A licensed physician must supervise the PA. 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. 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. The supervising physician must provide the PA with predetermined procedures and drug protocols. Review of the PAs records and co signature of the supervising physician is required.

48 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* *

49 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 page 21 49

50 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 page 21

51 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 page 21

52 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 page 21 52

53 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 page 21

54 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 “Non-Retiree Choice” retirees and TRW All groups

55 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 page 3

56 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?

57 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.

58 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

59 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

60 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

61 Questions?

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