AAPA reimbursement Advocacy Staff for Maryland
Michael Powe: [email protected]
AAPA Vice President of Reimbursement and Professional Advocacy
Stephanie Radix: [email protected]
Director, State Advocacy
AAPA online resources
AAPA >Your PA practice>Reimbursement >Maryland reimbursement
Maryland Academy of Physician Assistants
Director, reimbursement committee, Diane Stowers, [email protected]
Online Coding and Billing Courses
Centers for Medicare and Medicaid Services
Overview of Medicare
Medicare is a federally administered insurance program offered to those who are 65 years of age and older. Those younger than 65 may qualify if they have disabilities such as end-stage renal failure. The Centers for Medicare and Medicaid Services (CMS) administers the program, and the Social Security Administration is responsible for determining the eligibility of participants, processing payments, and assuring compliance with the regulations. Information on Medicare and how Medicare works can be found at medicare.gov or at http://www.medicare.gov/sign-up-change-plans/decide-how-to-get-medicare/whats-medicare/what-is-medicare.html
The different parts of the Medicare Program
Medicare has four parts (A, B, C, D). Part A is Hospital Insurance. In the past, Medicare allowed Hospital-Based PAs to bill under Part A through the hospital cost reports, which has changed (Medicare Claims Processing Manual Chapter 12, Section 120.1). If your hospital is billing for your services under part A contact MdAPA [email protected] or the AAPA at [email protected].
Medicare Part B is medical insurance. Medicare now requires physicians and NPPs (non-physician providers including PAs) to submit claims for their services under part B (except for administrative responsibilities). Therefore, it is important to understand the regulations set forth by CMS under part B. Medicare Part C, or Advantage plans, is another way for beneficiaries to receive their Part A, B and D benefits. Part D covers prescriptions drugs.
According to CMS “Medicare Part B (Medical Insurance) helps cover doctors’ services and outpatient care. It also covers other medical services that Part A doesn’t cover, such as physical and occupational therapists, and home health care. Part B helps pay for these covered services and supplies when they are medically necessary.”
Medicare And PAs
Medicare will reimburse for PA services under part B for services in doctor’s offices, hospitals, nursing facilities, and ambulatory surgery centers. Services must be in the scope of practice for the NPP (PA) and be allowed under state law. PAs are allowed to bill all levels of evaluation and management codes, consultations, initial hospital visits, hospital discharges, mental health services, and other services. The American Academy of Physician Assistants and the Maryland Academy of Physician Assistants work together to promote legislative and regulatory changes that limit reimbursement for PAs.
Payment by Medicare
Medicare requires services provided by PAs to be reimbursed at 85 percent of the physician fee schedule unless specific billing exceptions apply, e.g. incident to and shared billing (see explanations of these services in the frequently asked questions section). PAs must enroll in Medicare and receive an NPI (National Provider Identifier) and must bill at the full physician rate. The PA’s NPI number will alert CMS to pay at 85 percent. To enroll see the section on enrolling and credentialing.
Credentialing and Enrolling with Medicare and Private Payers
What is credentialing?
Credentialing is the process of assessing and verifying the qualifications of a health care provider such as licensing, certification, and education. Medicare, private payers, hospitals and other organizations credential health care providers including PAs.
What is enrolling?
Enrolling is the process of adding a provider’s credentials to the payer’s system. Medicare and private payers enroll health care providers and payment is rendered only to those providers who are enrolled.
How do I get credentialed and enrolled?
The first step is to get an NPI number.
The Health Insurance Portability and Accountability ACT (HIPPA) of 1996 requires the use of a standard unique identifier for health care providers. The CMS (Centers for Medicare and Medicaid Services) developed such a system, called the National Plan and Provider Enumeration System (NPPES).
This unique identifier, termed an NPI number, is a 10-digit number that is assigned to each provider of service and does not contain any information about the provider. The number stays with the provider regardless of job change or location change.
PAs and NPI numbers
Any entity, including PAs, who meet the federal definition of a “health care provider” at 45 CFR 160.103 may apply for an NPI number. The NPI numbers do not replace the Medicare enrollment process. PAs must also enroll in Medicare to receive payment from Medicare.
Getting an NPI
You can apply for a free NPI number at nppes.cms.hhs.gov
To apply you will need your contact and indentifying information (including Social Security Number) and State License Information.
PAs and Medicare
Medicare claims for PA services may be submitted under the PAs NPI number. PAs may submit claims under the supervising MD’s NPI number for “incident to” and shared visits. However, this renders the PA’s services invisible to Medicare and to statistical and research investigations. All health care providers must enroll directly on Form 855i at www.cms.gov or http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/suppliers.pdf
PAs and Maryland Medicaid
More than half of the states recognize PA’s NPI numbers and allow for Medicaid services to be billed under the PAs NPI number. Currently, Maryland requires the services to be billed under the MD’s NPI.
Enrolling with private (third party) providers
Enrollment varies by payer. Some payers enroll, credential, and allow the PA to bill under their NPI number. If the payer does not credential PA’s, then the PA should bill under the MD’s NPI number. However, this will render the PA’s services invisible. An overview of how private payers enroll, credential, and expect claims to be filed can be found in the section on payer profiles.
For more information regarding ICD-10 please click the links below
Any questions regarding ICD-10 contact [email protected]