Behavioral Health Provider Types

October 3rd, 2017 - Raquel

Categories: Behavioral Health|Psychiatry|Psychology

In the behavioral health profession there are a several different types of providers with varying degrees and credentials. Third party payer coverage, billing requirements, and reimbursement vary depending on the practitioner’s professional type or specialty. Also, it is important to be aware of individual state scope of practice laws.

This information presented here is based on the official Medicare definitions of providers, along with coverage information from a variety of sources such as Local Coverage Determinations (LCDs). It is important to note that many payers utilize similar guidelines.

Behavioral Health Care Manager<<Do you want the shading? Or just underlined and bolded.

Qualifications

The Behavioral health care manager must have formal education or specialized training in behavioral health. The CPT code book states that it refers to “clinical staff with a master-/doctoral-level education or specialized training in behavioral health.” CMS recognizes the following as acceptable disciplines:

social work,
nursing
psychology

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Behavioral-Health-Integration-Fact-Sheet.pdf

Role/Responsibilities

The Behavioral Health Care Manager works under the oversight and direction of the billing provider to perform proactive, systematic follow-up using validated rating scales and a registry (where applicable). According to CMS, they perform the following (required for CoCM; optional for General BHI):

<<This following is originally included in a medicare box, but I changed it a little before I found the description. So I’ll let you decide which way you want it?? The blue is from another portion of the document and is not word for word like medicare>>

Provides assessment and care management services, in consultation with the psychiatric consultant, including

o the administration of validated rating scales

o assess adherence, tolerability and clinical response of beneficiary to treatment

o behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes;

o provision of brief evidence-based psychosocial interventions

o ongoing collaboration with the billing practitioner

o maintenance of the registry

Available to provide services face-to-face with the beneficiary; has a continuous relationship with the beneficiary and a collaborative, integrated relationship with the rest of the care team.
Able to engage the beneficiary outside of regular clinic hours as necessary to perform the behavioral health care manager’s duties.
May or may not be a professional who meets all the requirements to independently furnish and report services to Medicare.
Does not include administrative or clerical staff; time spent in strictly administrative or clerical duties is not counted towards the time threshold to bill the BHI codes.
Provides assessment and care management services, including the administration of validated rating scales; behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes; provision of brief psychosocial interventions; ongoing collaboration with the billing practitioner; maintenance of the registry; al in consultation with the psychiatric consultant.
Available to provide services face-to-face with the beneficiary; has a continuous relationship with the beneficiary and a collaborative, integrated relationship with the rest of the care team.
Able to engage the beneficiary outside of regular clinic hours as necessary to perform the behavioral health care manager’s duties.
May or may not be a professional who meets all the requirements to independently furnish and report services to Medicare.
Does not include administrative or clerical staff; time spent in strictly administrative or clerical duties is not counted towards the time threshold to bill the BHI codes.

Reimbursement

Reimbursement is based on the “incident to” rules and regulations as well as state law, licensure, and scope of practice. The “incident to” regulation was revised to allow general supervision (rather than the more stringent direct supervision standard in place for most “incident to” services) for the CoCM and general BHI codes as well as the non-face-to-face portion of other designated care management services such as complex chronic care management.<<Have not seen anything in relationship to reimbursement, It does say the following: >>

Medicare will make separate payments to physicians and non-physician practitioners for BHI services they furnish to beneficiaries over a calendar month service period, using four new Medicare Part B billing codes

G0502; G0503; G0504 Psychiatric Collaborative Care Services (CoCM):

G0507 BHI Services other than CoCM
This code may be used to report models of care that do not involve a psychiatric consultant, nor designated behavioral healthcare manager. This code may be updated as more information is available regarding other types of BHI care models that are used.

Clinical Nurse Specialist (CNS)

Qualifications

Coverage <<see https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf>>

A clinical nurse specialist (CNS) must meet the applicable state requirements governing the qualifications for CNSs and meet all of the following requirements:

Be a registered nurse who is currently licensed to practice in the State where he or she practices and be authorized to furnish the services of a clinical nurse specialist in accordance with State law;
Have a master’s degree in a defined clinical area of nursing from an accredited educational institution; and
Be certified as a clinical nurse specialist by a recognized national certifying body that has established standards for CNS specialists.
He or she is legally authorized and qualified to furnish the services in the State where they are performed;
Services are not otherwise precluded due to a statutory exclusion, and the services must be reasonable and necessary;
Services are the type considered physicians’ services if furnished by a MD or a DO;<<Because there were others, I added this below under coverage. But, you might just want to leave it at this?>>
Services are performed in collaboration with a physician; In the absence of State law governing collaboration, collaboration is to be evidenced by the CNS documenting his or her scope of practice and indicating the relationships that the CNS has with physicians to deal with issues outside the CNS’ scope of practice.

The collaborating physician does not need to be present with the CNS when services are furnished or to make an independent evaluation of each patient seen by the CNS.

Assistant-at-surgery services furnished by a CNS are covered;
He or she may personally perform diagnostic psychological and neuropsychological tests in collaboration with a physician as required under the CNS benefit and to the extent permitted under State law; and
Incident to services and supplies may be covered.

Coverage

State law or regulations governing a CNS’ scope of practice in the State in which the services are furnished applies. The provider must develop a list of covered services based on the State scope of practice. Examples of the types of services that a CNS may furnish include services that traditionally have been reserved for physicians, such as:

physical examinations
minor surgery
setting casts for simple fractures
interpreting x-rays
other activities that involve an independent evaluation or treatment of the patient’s condition.
services billed under all levels of evaluation and management codes and diagnostic tests if furnished in collaboration with a physician and if authorized under the scope of his or her State license.

As a Qualified Professional they may under certain circumstances:

QUALIFIED PERSONNEL means staff (auxiliary personnel) who have been educated and trained as therapists and qualify to furnish therapy services only under direct supervision incident to a physician or NPP. See §230.5 of this chapter. Qualified personnel may or may not be licensed as therapists but meet all of the requirements for therapists with the exception of licensure.

If licensed by the state, they may appropriately furnish therapy services
He or she may personally perform diagnostic psychological and neuropsychological tests in collaboration with a physician as required under the NP benefit and to the extent permitted under State law;

Psychological Tests and Neuropsychological Tests

Under the diagnostic tests provision, all diagnostic tests are assigned a certain level of supervision. Generally, regulations governing the diagnostic tests provision require that only physicians can provide the assigned level of supervision for diagnostic tests. However, there is a regulatory exception to the supervision requirement for diagnostic psychological and neuropsychological tests in terms of who can provide the supervision. That is, regulations allow a clinical psychologist (CP) or a physician to perform the general supervision assigned to diagnostic psychological and neuropsychological tests.

In addition, nonphysician practitioners such as nurse practitioners (NPs), clinical nurse specialists (CNSs) and physician assistants (PAs) who personally perform diagnostic psychological and neuropsychological tests are excluded from having to perform these tests under the general supervision of a physician or a CP. Rather, NPs and CNSs must perform such tests under the requirements of their respective benefit instead of the requirements for diagnostic psychological and neuropsychological tests. Accordingly, NPs and CNSs must perform tests in collaboration (as defined under Medicare law at section 1861(aa)(6) of the Act) with a physician. PAs perform tests under the general supervision of a physician as required for services furnished under the PA benefit.

Reimbursement

CNSs are paid at 85% of the Medicare Physician Fee Schedule (MFPS) for most services. For assistant-at-surgery servicess, CNSs are paid at 85% of 16% of the amount paid a physician under the MPFS for assistant-at-surgery services.

A CNS may bill directly and receive direct payment for their services.

Assignment

Assignment is required for Medicare.

Clinical Psychologist (PsyD, PhD)

Qualifications

A Clinical Psychologist (CP) must meet the following requirements: <<Medicare boxes info checked>>

Hold a doctoral degree in psychology;
Be licensed or certified, on the basis of the doctoral degree in psychology, by the State in which he or she practices, at the independent practice level of psychology to furnish diagnostic, assessment, preventive, and therapeutic services directly to individuals.

Coverage

CPs are treated the same as physicians as long as state licensing requirements are satisfied. They are classified as “Allied Health Professionals/Nonphysician Practitioners” by Medicare.This was included here, but I’ve not found anything about it. If you do not qualify as a Clinical Psychologist, see the instructions under Independently Practicing Psychologist.

See Resource 209 to review the complete Medicare Benefit Policy Manual.

Qualified Clinical Psychologist Services Defined—Effective July 1, 1990, the diagnostic and therapeutic services of CPs and services and supplies furnished incident to such services are covered as the services furnished by a physician or as incident to physician’s services are covered. However, the CP must be legally authorized to perform the services under applicable licensure laws of the State in which they are furnished.
Types of Clinical Psychologist Services That May Be Covered:

Diagnostic and therapeutic services that the CP is legally authorized to perform in accordance with State law and/or regulation. Carriers pay all qualified CPs based on the physician fee schedule for the diagnostic and therapeutic services. (Psychological tests by practitioners who do not meet the requirements for a CP may be covered under the provisions for diagnostic tests as described in §80.2.

Services and supplies furnished incident to a CP’s services are covered if the requirements that apply to services incident to a physician’s services, as described in §60 are met. These services must be:

Mental health services that are commonly furnished in CPs’ offices;
An integral, although incidental, part of professional services performed by the CP;
Performed under the direct personal supervision of the CP; i.e., the CP must be physically present and immediately available;
Furnished without charge or included in the CP’s bill; and
Performed by an employee of the CP (or an employee of the legal entity that employs the supervising CP) under the common law control test of the Act, as set forth in 20 CFR 404.1007 and §RS 2101.020 of the Retirement and Survivors Insurance part of the Social Security Program Operations Manual System.
Diagnostic psychological testing services when furnished under the general supervision of a CP.

Non-covered Services—The services of CPs are not covered if the service is otherwise excluded from Medicare coverage even though a clinical psychologist is authorized by State law to perform them. For example, §1862(a)(1)(A) of the Act excludes from coverage services that are not “reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.” Therefore, even though the services are authorized by State law, the services of a CP that are determined to be not reasonable and necessary are not covered. Additionally, any therapeutic services that are billed by CPs under CPT psychotherapy codes that include medical evaluation and management services are not covered.

TIP: This “reasonable and necessary” requirement is practiced by all insurance carriers and can vary from state to state.

Requirement for Consultation—When applying for a Medicare provider number, a CP must submit to the carrier a signed Medicare provider/supplier enrollment form that indicates an agreement to the effect that, contingent upon the patient’s consent, the CP will attempt to consult with the patient’s attending or primary care physician in accordance with accepted professional ethical norms, taking into consideration patient confidentiality.

If the patient assents to the consultation, the CP must attempt to consult with the patient’s physician within a reasonable time after receiving the consent. If the CP’s attempts to consult directly with the physician are not successful, the CP must notify the physician within a reasonable time that he or she is furnishing services to the patient. Additionally, the CP must document, in the patient’s medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician.

The only exception to the consultation requirement for CPs is in cases where the patient’s primary care or attending physician refers the patient to the CP. Also, neither a CP nor a primary care nor attending physician may bill Medicare or the patient for this required consultation

Outpatient Mental Health Services Limitation—All covered therapeutic services furnished by qualified CPs are subject to the outpatient mental health services limitation in Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, “Deductibles, Coinsurance Amounts, and Payment Limitations,” §30, (i.e., only 62 1/2 percent of expenses for these services are considered incurred expenses for Medicare purposes). The limitation does not apply to diagnostic services.

Psychological Tests and Neuropsychological Tests:

Note:

CPs should typically bill with modifier “AH”. See the Behavioral Health DeskBook Reimbursement Guide for Behavioral Health for information on completing the 1500 Claim Form and more information about modifier usage. It is available in the online store. See https://instacode.com/store/2018-reimbursement-guide-behavorial-health <<Do you want to refer them to the website?>>
The provider’s NPI must be on the claim form. See Chapter 3.2 — HIPAA Compliance in the Behavioral Health DeskBook for more information on the NPI.<<You asked if this is still relevant?>>

Reimbursement

Services are paid at 100% of the amount a physician is paid under the Medicare Physician Fee Schedule (MPFS).

Assignment

Assignment is required for Medicare.

Clinical Social Worker (CSW)

Qualifications <<Medicare boxes info checked>>

Medicare classifies CSWs as “Allied Health Professionals/Nonphysician Practitioners.” They must meet the following requirements:

Possesses a master’s or doctor’s degree in social work;
Has performed at least two years of supervised clinical social work; and
Is licensed or certified as a clinical social worker by the State in which the services are performed; or
In the case of an individual in a State that does not provide for licensure or certification, has completed at least 2 years or 3,000 hours of post master’s degree supervised clinical social work practice under the supervision of a master’s level social worker in an appropriate setting such as a hospital, SNF, or clinic.

Coverage

Clinical Social Worker Services Defined—Section 1861(hh)(2) of the Act defines “clinical social worker services” as those services that the CSW is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) of the State in which such services are performed for the diagnosis and treatment of mental illnesses. Services furnished to an inpatient of a hospital or an inpatient of a SNF that the SNF is required to provide as a requirement for participation are not included. The services that are covered are those that are otherwise covered if furnished by a physician or as incident to a physician’s professional service.
Covered Services—Coverage is limited to the services a CSW is legally authorized to perform in accordance with State law (or State regulatory mechanism established by State law). The services of a CSW may be covered under Part B if they are:

The type of services that are otherwise covered if furnished by a physician, or as incident to a physician’s service. (See §30 for a description of physicians’ services and §70 of Pub 100-1, the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, for the definition of a physician.);
Performed by a person who meets the definition of a CSW (See subsection A.); and
Not otherwise excluded from coverage

Non-covered Services—Services of a CSW are not covered when furnished to inpatients of a hospital or to inpatients of a SNF if the services furnished in the SNF are those that the SNF is required to furnish as a condition of participation in Medicare. In addition, CSW services are not covered if they are otherwise excluded from Medicare coverage even though a CSW is authorized by State law to perform them. For example, the Medicare law excludes from coverage services that are not “reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.”
Outpatient Mental Health Services Limitation—All covered therapeutic services furnished by qualified CSWs are subject to the outpatient psychiatric services limitation in Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, “Deductibles, Coinsurance Amounts, and Payment Limitations,” (§30, (i.e., only 62 ½ percent of expenses for these services are considered incurred expenses for Medicare purposes). The limitation does not apply to diagnostic services.

TIP: State laws or other regulatory agencies may differ in your area. Be aware of services that are within your state scope of practice.

Reimbursement

Payment is made only on an assignment basis and are paid at 75% of the amount paid a CP under the Medicare Physician Fee Schedule (MPFS).

Assignment

Assignment is required for Medicare.

Independently Practicing Psychologist (IPP)

Qualifications

Independently Practicing Psychologists (IPP) must meet the following qualifications:

Have a doctoral degree in psychology from a program other than clinical psychology i.e., educational or behavioral, of an educational institution that is accredited by an organization recognized by the Council on Post-Secondary Accreditation; and This first one I have not found.
Be licensed or certified to practice psychology in the State or jurisdiction where furnishing services or, if the jurisdiction does not issue licenses, if provided by any practicing psychologist.

Psychologists are practicing independently when:

They render services on their own responsibility, free of the administrative and professional control of an employer such as a physician, institution, agency;
The persons they treat are their own patients; and
They have the right to bill directly, collect and retain the fee for their services.

A psychologist practicing in an office located in an institution may be considered an independently- practicing psychologist when both of the following conditions exist:

The office is confined to a separately-identified part of the facility which is used solely as the psychologist’s office and cannot be construed as extending throughout the entire institution; and
The psychologist conducts a private practice, i.e., services are rendered to patients from outside the institution as well as to institutional patients

Coverage

IPPs can perform diagnostic psychological and neuropsychological testing (CPT codes 96101-96120) in an office setting when a physician orders such testing, and are covered if medically necessary. No therapeutic services are covered by Medicare Part B<<I haven’t found this one>>. Psychologist services provided in a Medicare certified Community Mental Health Center (CMHC) must be billed to the fiscal intermediary.

Assignment

For Medicare, Independent psychologists are not required by law to accept assignment when performing psychological tests. However, regardless of whether the psychologist accepts assignment, he or she must report on the claim form the name and address of the physician who ordered the test.

Note: The provider’s NPI must be on the claim form. See Chapter 3 — Compliance Essentials in the Reimbursement Guide for Behavioral Health for more information on the NPI. <<is it still there?>>

Master’s Level Psychologist<<didn’t find anything more on this one.

Medicare does not have a specific category for this level of psychologist.

Qualifications

A master level psychologist must meet the applicable State Requirements governing the qualifications for non-doctorate psychologists for the state in which they will be practicing. Check with the Division of Occupational and Professional Licensing of the applicable state to ensure that all current qualifications are met.

Coverage

Coverage will vary from one insurance payer to another. It is always wise to verify coverage through the carrier before seeing the client. This is even more crucial to the Masters Level Psychologist because further limitations may apply. For legal purposes, it might be wise to adopt a policy to have a percentage of your cases reviewed by a doctoral level psychologist or psychiatrist on an annual basis. This demonstrates concern for optimal quality of care for clients. Your malpractice insurance carrier may also have guidelines that would be beneficial for you to follow.

Nurse Practitioner (NP)

Qualifications

A Nurse Practitioner (NP) must meet all of the following conditions for Medicare:

Be a registered professional nurse who is authorized by the State in which the services are furnished to practice as a nurse practitioner in accordance with State law; and be certified as a nurse practitioner by a recognized national certifying body that has established standards for nurse practitioners; or
Be a registered professional nurse who is authorized by the State in which the services are furnished to practice as a nurse practitioner by December 31, 2000.

The NPs applying for a Medicare billing number for the first time on or after January 1, 2001, must meet the requirements as follows:

Be a registered professional nurse who is authorized by the State in which the services are furnished to practice as a nurse practitioner in accordance with State law; and
Be certified as a nurse practitioner by a recognized national certifying body that has established standards for nurse practitioners.

The NPs applying for a Medicare billing number for the first time on or after January 1, 2003, must meet the requirements as follows:

Be a registered professional nurse who is authorized by the State in which the services are furnished to practice as a nurse practitioner in accordance with State law;
Be certified as a nurse practitioner by a recognized national certifying body that has established standards for nurse practitioners; and
Possess a master’s degree in nursing

Coverage

Covered Services—Coverage is limited to the services an NP is legally authorized to perform in accordance with State law (or State regulatory mechanism established by State law).
General - The services of an NP may be covered under Part B if all of the following conditions 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 the definition of an NP (see subsection A);
The NP is legally authorized to perform the services in the State in which they are performed;
They are performed in collaboration with an MD/DO (see subsection D); and
They are not otherwise precluded from coverage because of one of the statutory exclusions. (See subsection C.2.)

Incident To

If covered NP services are furnished, services and supplies furnished incident to the services of the NP may also be covered if they would have been covered when furnished incident to the services of an MD/DO as described in §60.

Application of Coverage Rules
Types of NP Services That May Be Covered—State law or regulation governing an NP’s scope of practice in the State in which the services are performed applies. Consider developing a list of covered services based on the State scope of practice. Examples of the types of services that NP’s may furnish include services that traditionally have been reserved to physicians, such as physical examinations, minor surgery, setting casts for simple fractures, interpreting x-rays, and other activities that involve an independent evaluation or treatment of the patient’s condition. Also, if authorized under the scope of their State license, NPs may furnish services billed under all levels of evaluation and management codes and diagnostic tests if furnished in collaboration with a physician. See §60.2 for coverage of services performed by NPs incident to the services of physicians.
Services Otherwise Excluded From Coverage—The NP services may not be covered if they are otherwise excluded from coverage even though an NP may be authorized by State law to perform them. For example, the Medicare law excludes from coverage routine foot care, routine physical checkups, and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Therefore, these services are precluded from coverage even though they may be within an NP’s scope of practice under State law.
Collaboration—Collaboration is a process in which an NP works with one or more physicians (MD/DO) to deliver health care services, with medical direction and appropriate supervision as required by the law of the State in which the services are furnished. In the absence of State law governing collaboration, collaboration is to be evidenced by NPs documenting their scope of practice and indicating the relationships that they have with physicians to deal with issues outside their scope of practice.

The collaborating physician does not need to be present with the NP when the services are furnished or to make an independent evaluation of each patient who is seen by the NP.

As a Qualified Professional they may under certain circumstances:

If licensed by the state, they may appropriately furnish therapy services
He or she may personally perform diagnostic psychological and neuropsychological tests in collaboration with a physician as required under the NP benefit and to the extent permitted under State law;

Assistant-at-surgery services furnished by a NP are covered; <<I couldn’t find anything stating this, although above it does say they can perform minor surgery. #1 under C.>>

Reimbursement

NPs are paid at 85 percent of the Medicare Physician Fee Schedule for most services. For assistant-at-surgery services, NPs are paid at 85% of 16% of the amount paid a physician under the Medicare PFS for assist and-at-surgery services.

Direct billing and payment for NP services may be made to the NP.

Assignment

Assignment is required for Medicare

Psychiatric Consultant

Qualifications

A Psychiatric Consultant: must be a medical professional (e.g., a psychiatrist or an NP with psychiatry board-certification) trained in psychiatry and qualified to prescribe the full range of medications.

Role/Responsibilities

The psychiatric consultant advises and makes psychiatric and other medical care recommendations that are communicated to the treating physician, typically through the Behavioral Health Care Manager. The psychiatric consultant does not typically see the beneficiary or prescribe medications, except in rare circumstances, but should facilitate referral for direct psychiatric care when clinically indicated.

According to Medicare, the Psychiatric Consultant’s responsibilities include the following:

Participates in regular review of clinical status of patients receiving BHI services.
Advises the billing practitioner (and behavioral health care manager) regarding diagnosis;
indicates options for resolving issues with beneficiary adherence and tolerance of behavioral health treatment;
makes adjustments to behavioral health treatment for beneficiaries who are not progressing;
manages any negative interactions between beneficiaries’ behavioral health and medical treatments.
Can (and typically will) be remotely located;
is generally not expected to have direct contact with the beneficiary, nor prescribe medications or furnish other treatment to the beneficiary directly.
Can and should facilitate referral for direct provision of psychiatric care when clinically indicated.

Reimbursement

Reimbursement based on the “incident to” rules and regulations as well as state law, licensure, and scope of practice. The “incident to” regulation was revised to allow general supervision (rather than the more stringent direct supervision standard in place for most “incident to” services) for the CoCM and general BHI codes as well as the non-face-to-face portion of other designated care management services such as complex chronic care management.

Psychiatric Nurse Practitioner (PNP)

Psychiatric Nurse Practitioners must meet all the qualifications for NPs. See Page 7 for coverage and assignment requirements. In addition, they must also:

Be licensed as a nurse practitioner certified in psychiatric nursing by the state or jurisdiction.

Physicians (MD, DO)

Qualifications

A physician must meet the following requirements:

Holds a medical doctorate degree.
Meets licensing standards as a physician in the state(s) in which he/she practices.

Coverage

Physician coverage includes Evaluation and Management (E/M) services, pharmacological management, psychiatric interview procedures, individual and group psychotherapy, and other psychiatric therapy provided in any setting (e.g., office, institution, patient’s home). Services can either be personally performed by the physician or by an employee under the physician’s direct supervision as an “incident to” service.

Reimbursement

Payment is based on the Physician Fee Schedule (PFS). Some services are based on the Medicare Physician Fee Schedule (MPFS).

Assignment

Assignment for Medicare is not required, unless the physician has entered into a participating agreement.

Physicians must acquire and use their National Provider Identifier (NPI) to submit claims.

Store: See the Reimbursement Guide for Behavioral Health for more information on Evaluation and Management coding, Medicare participation, and NPIs. It is available in the online store.

<<Do you want this here?>>

Physician Assistant (PA)

Qualifications <<Medicare boxes info checked>>

A Physician Assistant (PA) must meet the following conditions:

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.

Coverage

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).
General: The services of a PA may be covered under 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.

Incident To—If covered PA services are furnished, services and supplies furnished incident to the PA’s services may also be covered if they would have been covered when furnished incident to the services of an MD/DO, as described in §60
Types of PA Services That May Be Covered—State law or regulation governing a PA’s scope of practice in the State in which the services are performed applies. Carriers should consider developing lists of covered services. Also, if authorized under the scope of their State license, 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.

Examples of the types of services that PAs may provide include services that traditionally have been reserved to physicians, such as physical examinations, minor surgery, setting casts for simple fractures, interpreting x-rays, and other activities that involve an independent evaluation or treatment of the patient’s condition.

See §60.2 for coverage of services performed by PAs incident to the services of physicians

Note: “Incident To” information is included in the Reimbursement Guide for Behavioral Health available in the online store.<<Do you want the link here>>

Reimbursement

PAs are paid at 85% of the Medicare Physician Fee Schedule (MFPS) for most services. For assistant-at-surgery servicess, PAs are paid at 85% of 16% of the amount paid a physician under the MFPS for assistant-at-surgery services.

Additionally, payments may be made only to the PA’s qualified employer who is eligible to enroll in the Medicare Program under existing provider/supplier categories; or contractor.

Assignment

Assignment is required for Medicare.

Treating (Billing) Practitioner

A Treating Practitioner is one of the following:

physician and/or non-physician practitioner (PA, NP, CNS, CNM)
Typically primary care, but may be of another specialty (e.g., cardiology, oncology, psychiatry)
He or she is legally authorized and qualified to furnish the services in the State where they are performed;
Performs the initial visit required to establish the relationship with the beneficiary as the the billing practitioner. Assuring the assessment of the beneficiary prior to initiating BHI services
Directs behavioral health care manager or clinical staff.
Oversees care of the beneficiary, including: prescribing medications; providing treatments for medical conditions; making referrals for specialty care as needed.
Remains involved through ongoing oversight, management, collaboration and reassessment.
May provide General BHI services in its entirety.

Qualifications:

###

Questions, comments?

If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.

Latest articles: (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox

We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities?

Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code

Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.

ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox

Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.

Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox

According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.

Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox

With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.

COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli

COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.

Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli

2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....