Notification



Notification Issue Date:



Claim Payment Policy


Title:Incident To and Non-Incident To Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs)

Policy #:00.10.40d


Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, 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. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



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


Coverage is subject to the terms, conditions, and limitations of the member's contract.

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 Non-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

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A


Misc Code

Modifiers:

SA - Nurse practitioner rendering service in collaboration with a physician



Coding and Billing Requirements


Cross References

 Policy: 00.01.25ax:PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services

 Policy: 00.03.07y:Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products

 Policy: 00.03.09d:X-rays Associated with Fractures in the Office Setting

 Policy: 00.03.10e:Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product

 Policy: 00.10.01ab:Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers

 Policy: 00.01.55o:New Jersey Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Radiology Network Rules and Limited Circumstances


Policy History

REVISION FROM 00.10.40d
09/23/2019This version of the policy will become effective 09/23/2019.

This version of the policy clarifies the description and criteria for services that are not considered Incident To.

REVISION FROM 00.10.40c
06/01/2019This version of the policy will become effective 06/01/2019.

The title of the policy was changed to "Incident To and Non-Incident To Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs)" from "Reimbursement for Services Performed by Certified Registered Nurse Practitioners (CRNPs) or Physician Assistants (PAs)".

This version of the policy adds language explaining how Certified Registered Nurse Practitioners (CRNPs) and Physician Assistant (PAs) are reimbursed. CRNPs and PAs are reimbursed at 100% of the standard physician fee schedule for services that are Incident To a supervising physician's professional services and 85% of the standard physician fee schedule for services that are not Incident To.

REVISION FROM 00.10.40b
12/01/2017Effective 12/01/2017, Physician Assistants (PAs) are eligible to perform services in in a specialty group.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 09/23/2019
Version Issued Date: 09/23/2019
Version Reissued Date: N/A



2017 AmeriHealth.