Physician Assistant and Nurse Practitioner Reimbursement The Balanced Budget Act of 1997 allowed Medicare Part B direct billing by Physician Assistants (PAs) and Nurse Practitioners (NPs). Reimbursement is set at 85% of the Physician Fee Schedule effective January 1, 1998. Many PAs and NPs can qualify both as independent practitioners, and as Non-Physician Providers (NPPs) providing services “incident to” physician services. Often physician practices have continued to bill the services of NPPs as “incident to” those provided by physicians. However, this is not always the most advantageous method for reimbursement. There are limitations to “incident to” billing and all the requirements must be met in order to properly bill under this provision. Coding for “incident to” services is limited to the lowest established office service, 99211. And, while claim assignment is not required under the “incident to” provision since the claim is submitted under the physician’s provider number, payment is restricted to this level of service. Initiation of “direct billing” for NPPs, however, is also not without difficulties. Provider numbers must be obtained prior to initiation of billing. The Medicare carrier has published conflicting information about the need to include or exclude the appropriate modifiers that have been appended to service coding in the past. There is confusing information about the inclusion or exclusion of NPPs into physician billing group numbers for billing purposes. Payment from the Medicare program is always made on an assigned basis for PAs and NPs. The key deciding factor as to whether the services of the NPPs may be submitted for payment is to remember that “incident to” and direct professional billing may not be submitted if the facility, or any other provider, is receiving payment for furnishing the same services. This is considered duplicate billing, and is in direct violation of federal regulations. A word of caution – any inaccurate reporting of services, such as qualification of the provider, employment relationship, or the wrong place of service may qualify as a false claim. Requirements for PA Reimbursement Medicare will directly reimburse for PA services performed in accordance with state law. There is no restriction as to the place of service. The physician supervisor, while not required to be present with the PA while the service is performed unless required by state law, must be primarily responsible for the overall management and direction of the PAs professional activities. The physician supervisor must be immediately available by some form of reliable communication. Claims submitted for PA services must be reported with the PAs provider identification number (PIN). All claims, whether billed directly under the PA's PIN or “incident to” must include the correct PIN per line of coding. This will ensure correct payment by the carrier. As recently as April 1999, the Medicare carrier has published regulations that state that NPPs do not have to include identifying modifiers for services provided, with the exception of the “AS” modifier which indicates that a surgical procedure was performed by a PA. NP Reimbursement Medicare will directly reimburse those services that an NP is legally authorized by state law to perform. As with PAs, there is no limitation to the place of service or where the services may be performed. NPs are required to collaborate with a physician in order to deliver services within the scope of professional expertise. The collaborating physician does not have to be physically present during the service performed by the NP, but must be immediately available for communication as necessary. All NPs must have PINs whether the claims are submitted as “incident to” or for direct reimbursement. Return to Contents | Return to Billing Compliance