MA PPO

Incident To and Non-Incident To Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs)
MA00.045d


Policy

Refer to the following News Article:

Direct Supervision Requirements for Incident to Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs) in Response to COVID-19


The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

Services performed on a fee-for-service basis by a Certified Registered Nurse Practitioner (CRNP) or Physician Assistant (PA) that are Incident To a supervising physician's professional services will be reimbursed at 100 percent of the standard physician fee schedule, subject to the specific terms and conditions of the participation agreement.

Services performed on a fee-for-service basis by a CRNP or PA that are not Incident To a supervising physician's professional services will be reimbursed at 85 percent of the standard physician fee schedule, except in cases where the specific terms and conditions of the participation agreement that covers the CRNP or PA state otherwise.

Covered vaccines and injectables are eligible for reimbursement consideration by the Company at 100 percent of the standard vaccine and injectable fee schedule.

This policy does not apply to professional providers in hospital-based specialties (e.g. hospitalist, emergency medicine), nor does it apply to urgent care practices.

INCIDENT TO SERVICES

All of the following criteria are requirements for a service to be recognized as Incident To:
  • The individual seeking treatment must be an established patient, and the service must be treatment for an existing problem.
  • The treatment course must have been initiated by a physician at a previous encounter.
  • The service must be an integral part of the patient's course of treatment.
  • The physician must remain involved in the treatment plan.
  • The service must be of a type commonly furnished in a physician’s office or clinic (not in an institutional setting).
  • The service performed by the CRNP or PA must be provided under direct supervision of the physician, meaning the supervising physician (or a supervising partner) must be in the same office suite to render assistance if necessary.
  • The service must be an expense to the physician's practice.

NON-INCIDENT TO SERVICES

Services provided by CRNPs or PAs that do not meet all of the criteria stated above are considered Not Incident To.

The following are examples of situations that are not recognized as Incident To:
  • The individual seeking treatment is a new patient.
  • The individual seeking treatment is an established patient presenting with a new problem or condition.
  • The individual seeking treatment is presenting for consultation services.

BILLING REQUIREMENTS

For Incident To services performed by a CRNP or PA, the supervising physician should bill using their own National Provider Identifier (NPI) and report modifier SA. For services that are not Incident To a physician’s professional services, a CRNP or PA should bill using their own NPI.

Guidelines

Refer to the Professional Provider Credentialing requirements located on the Company’s website for information regarding participation and credentialing of CRNPs and PAs in the Company’s network.

Appropriate documentation should be included in the medical record demonstrating that Incident To criteria have been met.

For products with primary care provider capitation, services rendered by a CRNP or PA working in a primary care group are considered part of capitation, with the exception of those services outlined in the Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers policy.

Description


Incident To services are those services that are furnished "incident to" physician professional services in the physician's office or in the individual's home if the individual is homebound. The supervising physician does not need to be physically present in the treatment room while Incident To services are provided; however, the supervising physician must provide direct supervision, meaning the supervising physician (or a supervising partner) must be in the same office suite to render assistance if necessary.

Non-Incident To services are those personally performed by the CRNP or PA without direct supervision from a physician.

References

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual Chapter 15: Covered Medical and Other Health Services. [CMS Web site]. 11/30/2018. Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed January 11, 2019.

Centers for Medicare & Medicaid Services (CMS). MLN Matters SE0441. [CMS Web site]. Available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf. Accessed February 14, 2019.

Provider Contracts

Coding

CPT Procedure Code Number(s)
N/A

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
N/A

HCPCS Level II Code Number(s)
N/A

Revenue Code Number(s)
N/A

Modifiers

SA - Nurse practitioner rendering service in collaboration with a physician

Coding and Billing Requirements



Policy History

9/23/2019
9/23/2019
MA00.045
Claim Payment Policy Bulletin
Medicare Advantage
Yes