Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Medical services rendered by Physician Extenders (licensed Advanced Practice Nurses (APN) and Physician Assistants (PA)) will be covered within their legal scope of practice, based on specific contract terms. While APNs can practice independently with a collaborating physician agreement, some APNs, instead of practicing independently, choose to practice as Physician Extenders with a supervising physician, PAs cannot practice independently and can only practice with a supervising physician.

1)    Covered medical services provided by APNs or PAs must be concordant with the specialty of the collaborative/supervising physician.

2)    Services provided by Physician Extenders to outpatients are limited to presenting problems of low to moderate severity, and requiring medical decision making of similar level.  Patients with more severe problems must be referred to a physician.

3)    Services provided by Physician Extenders to inpatients are limited to:

a)     Follow up services provided to patients who are substantially recovering, and

b)     Discharge services.

4)    Assistant surgeon services provided when the supervising/collaborating physician is the primary surgeon are also covered.

5)    Covered Medical Services provided by APNs or PAs incident to physician services must meet CMS standards for incident to services.

6)    Services provided by Physician Extenders in the Emergency Department are not eligible for incident to billing.  Such services may be eligible for billing as split services when the supervising physician has a face-to-face encounter with the patient.  In that case, the services may be billed either by the physician or by the Physician Extender, though not both.  If a patient seen in the Emergency Department by a Physician Extender is not seen by the supervising physician, only the Physician Extender may bill for the visit.

QualChoice reimburses services provided by Physician Extenders based on CMS standard methodologies, AR state law, QualChoice contract terms, and the appropriate QualChoice fee schedule.

Direct Billing:  An APN eligible to bill QualChoice directly will be reimbursed for Covered Medical Services at the contracted rate.  A group employing a PA eligible to bill QualChoice directly will be reimbursed for Covered Medical Services at contracted rates.

Incident-to services:  Physician Extenders may under certain circumstances bill for their services as “incident-to” physician services, under the NPI of the supervising/collaborating physician.  These services will be reimbursed at the physician fee schedule only if ALL the following are met:

i)     Physician Extender is an employee of the supervising/collaborating physician or the entity that employs the physician.

ii)    The physician is present in the immediate patient care area and available to provide immediate assistance and direction throughout the time the Physician Extender is providing care.  This does not imply that the physician must be in the same room, but does mean the physician must be within the office suite and not engaged in activities that would prevent the physician from immediately going to the patient’s room.

iii)   Only services rendered in a private physician office or clinic are eligible to be considered as “incident to” services – services provided in a hospital ER, hospital clinic, home, or to a patient who is a resident in a hospital, convalescent hospital, nursing home, rehabilitation facility, or other residential facility may not be billed as “incident to” services.  The only exception would be a home visit at which both the physician and the physician extender are in attendance on the patient at the same time.

iv)   The physician is actively involved in the decision-making process for care of the patient. The Physician Extender must document in the patient’s medical record the active involvement of the physician in the decision-making process. Actively involved means that the physician is sufficiently aware of the patient’s current condition to endorse or intervene in the patient’s care in a timely manner, and that the physician must have initiated the care for the particular injury or illness for which the patient is being treated.  Thus, a Physician Extender may bill “incident to” for a follow up visit for a particular condition, but not for an initial visit for that condition.  Additionally, there must be subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment.

v)    The physician provides documentation/attestation of the collaboration/supervision in the patient’s medical record by co-signing and dating the patient’s medical record on the date the service is rendered.

vi)   The supervising/collaborating physician is credentialed by QualChoice or another entity to which QualChoice delegates credentialing.

Assistant Surgeon Services:  QualChoice will reimburse for assistant at surgery services when:

1)    The procedure is one of the procedure codes approved by QualChoice to be payable to an assistant surgeon; AND

2)    The Physician Extender is employed by a physician or physician group and not by the hospital; AND

3)    Assistant surgeon services are billed under the Physician Extender’s provider identification/NPI number with the appropriate modifier.

Codes Used In This BI:

1.    Physician Extenders are not eligible for reimbursement of higher level (level 5) EM codes (99205, 99215, 99285). For this level of complexity, direct physician involvement is expected.

2.    Physician Extenders are not eligible for reimbursement of inpatient admissions or for higher level inpatient care. 

Addendums:

1)    Effective 04/01/2020: Language added to more clearly distinguish between practice settings for APNs and PAs.

2)    Effective 01-01-2021: Updated deleted code 99201 replaced by 99202.  Updated revised codes 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215.  Added codes 99205, 99215 & 99285 to the search box as well as their descriptions to the codes used in this BI since they were listed in the claims statement.