Medicare


Medicare covers services provided by physician assistants in all settings at 85 percent of the physician's fee schedule, including hospitals (inpatient, outpatient, and emergency departments). For physician assistants and their employers, it's important to understand Medicare's requirements as it relates to PAs.  

Physician Supervision | Enrollment | NPIs | “Incident to” Billing | Medicaid |
Billing When Physician & PA Care for Same Patient   

Physician Supervision

Medicare requires that there be general supervision between the physician and the PA in accordance with state law. This means that there must be access to electronic communication between the physician and the PA, such as via telephone.

In the emergency department setting, PAs are not subject to Medicare's two other more restrictive levels of supervision, direct (requiring the physician to be in the departmental suite) and personal (requiring that the physician be in the same exam room).

And while Medicare does not require that the physician be physically present in the ED, the supervising physician is ultimately responsible for the medical services and procedures performed by the PA.

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Enrollment

Physician assistants wanting to enroll to be a Medicare provider must meet the following requirements:

  • Graduated from a PA education program accredited by the Accreditation Review Commission on Education for the Physician Assistant

(If prior to 2001, the PA must have graduated from a PA program accredited by either the Committee on Allied Health Education and Accreditation or the Commission on Accreditation of Allied Health Education Programs)

OR

  • Passed the national certification examination of the National Commission on Certification of Physician Assistants (NCCPA)
  • Licensed by the state he or she is practicing in

Physician assistants can apply for enrollment in the Medicare program or make a change in their enrollment information using either:

Additional information on enrollment, is available by the U.S. Department of Health & Human Services Centers for Medicare & Medicaid Services.

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NPIs

The National Provider Identifier (NPI) number is a unique identification number for covered health care providers. Mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPPA), the NPI is a 10-digit number used for the administrative and financial transactions adopted under HIPAA. The NPI does not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.

Apply online for an NPI at the U.S. Department of Health & Human Services Centers for Medicare & Medicaid Services or by calling the Enumerator at 1-800-465-3203 or TTY 1-800-6922326. It should take about two weeks to receive your NPI number.

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"Incident to" Billing

"Incident to" is a Medicare provision in which a PAs services are reimbursed at 100 percent of the physician fee by billing using the physician's NPI. However, Medicare does not allow "incident-to" billing in the emergency department.

Medicare only covers "incident to" billing for services performed by a PA in an office or clinic setting if the following are met regarding the services:

  • Commonly performed in physician's office
  • Commonly rendered either without charge or included in the RHC or FQHC's bill
  • Provided as an incidental, although integral, part of professional services provided by a the physician assistant
  • Provided under the direct, personal supervision of a physician or physician assistant
  • Provided by a member of the clinic or center's staff who is an employee of the clinic or center

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Medicaid

Medicaid is administered by the states. It's the individual state that determines if a physician assistant can provide services and their reimbursement schedule.

All states currently cover the services provided by PAs through Medicaid's fee-for-service or managed care plans. Billing for those services does vary from state to state. However, the services are typically reimbursed at the same or a lower rate than that of a physician.

For detailed information on your state's policy on Medicaid coverage for PAs, see the AAPA's state surveys.

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Billing When Physician & PA Care for Same Patient

A physician and physician assistant can provide services to the same patient and get reimbursed at 100 percent of the fee schedule if the following criteria are met:

  • Physician and PA have a common employer
  • Physician and PA saw the patient on the same calendar day
  • Physician and PA's services are clearly documented on the patient's chart
  • Service provided is not a consultation emergency medicine service, procedure, or a critical care service
  • Physician provided some face-to-face services during the visit (reviewing and/or signing the patient's chart does not qualify) 

If these criteria are met, the physician and PA's combined services can be billed under the physician's NPI number for reimbursement at 100 percent of the fee schedule.

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