Coverage Policies

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 04/01/2012 Title: Physician Extenders
Revision Date: 01/01/2018 Document: BI344:00
CPT Code(s): 99201-99204, 99211-99214, 99217, 99218, 99224, 99231, 99238, 99239, 99281-99284, 99307-99309, 99315, 99316, 99324-99327, 99334-99336, 99341-99344, 99347-99349
Public Statement

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.

1)    Covered medical services provided by Physician Extenders 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 Physician Extenders incident to physician services must meet CMS standards for incident to services.

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.

Medical Statement

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.

 

99201

Office/outpatient visit new

99202

Office/outpatient visit new

99203

Office/outpatient visit new

99204

Office/outpatient visit new  

99211

Office/outpatient visit est

99212

Office/outpatient visit est

99213

Office/outpatient visit est

99214

Office/outpatient visit est

99217

Observation care discharge

99218

Initial observation care

99224

Subsequent observation care

99231

Subsequent hospital care

99238

Hospital discharge day

99239

Hospital discharge day

99281

ER visit

99282

ER visit

99283

ER visit

99284

ER visit

99307

Nursing fac care subseq

99308

Nursing fac care subseq

99309

Nursing fac care subseq

99315

Nursing fac discharge day

99316

Nursing fac discharge day

99324

Domicil/r-home visit new pat

99325

Domicil/r-home visit new pat

99326

Domicil/r-home visit new pat

99327

Domicil/r-home visit new pat

99334

Domicil/r-home visit est pat

99335

Domicil/r-home visit est pat

99336

Domicil/r-home visit est pat

99341

Home visit new patient

99342

Home visit new patient

99343

Home visit new patient

99344

Home visit new patient

99347

Home visit est patient

99348

Home visit est patient

99349

Home visit est patient


Limits

1.     Physician Extenders are not eligible for reimbursement of higher level (level 5) EM codes. 

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


Application to Products
This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.