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 has myriad policies and regulations PAs must follow in order to avoid allegations of fraud and abuse.
The following articles detail Medicare policy for billing for services provided by PAs. (Member login required.)
Medicare “incident to” billing
“Incident to” (PDF) 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 percent. Strict criteria must be met.
Medicare shared visit billing
Shared visit billing (PDF) 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 percent.
Medicare and the Use of Scribes
It is important to distinguish between the service of a scribe, which is solely to document and encounter, and the medical evaluation and management services provided by a PA, which is the performance of the medical encounter itself.
Medicare and PECOS enrollment
Physician assistants must apply (PDF) first for an NPI number, then enroll in Medicare via the Provider Enrollment, Chain and Ownership System (PECOS).
Medicare: qualifications and coverage for services provided by PAs
The Medicare Manual describes the qualifications for PAs, the services that are covered when provided by PAs and the physician supervision requirements for PAs under the Medicare program.
Medicare preventive services
PAs may provide Medicare Preventive Services (PDF), including the “Welcome to Medicare” exam and “Annual Wellness Visits.” Learn about the rules, requirements, limitations and screening schedules for these services.
Durable Medical Equipment (DME)
Under Medicare, PAs are authorized to write the order and sign the certificate of medical necessity for durable medical equipment items prescribed to Medicare beneficiaries. Language contained in section 6407 of the Affordable Care Act (ACA) mandates that, for certain DME, a physician, PA, NP, or CNS have a face-to-face encounter with a Medicare beneficiary to assess that patient’s need. The visit must occur within the last six months before writing an order for select DME items. PAs are authorized to perform the visit, document the visit occurred and write the prescription for DME with no direct physician involvement.
First assisting at surgery
Learn about the billing rules for first assisting (PDF), the Medicare exclusion list and Teaching Facility Rules.
Pre-op history and physical examination
The pre-op H+P (PDF) is generally not a billable encounter because it is considered part of the “global package.”
Home health services
Read about the new home health requirements (PDF) for a face-to-face visit, which a PA may provide.
Supervision of diagnostic tests – Medicare
The billing rules for diagnostic tests (PDF) require that Medicare providers meet a specified level of physician supervision to bill for certain tests.