Changes to CMS Rules PAs Should Know
PAs need to understand the changes in CMS rules so that they are not breaking the law. Another aspect of understanding these rules is to communicate your value to an organization. What a PA brings to an organization is more than just dollars. However, understanding what you can bill out or how you receive payments as a PA will help you put a number to your value. A recent article from the AAPA shows some of the changes to the CMS physician fee schedule rules.
There will be changes to the following areas; direct payments for PAs, split/shared visit billing, behavioral health flexibilities, RHC and FQHC-employed hospice attending physicians, and direct supervision. The first thing to keep in mind about these rules is that they apply to Medicare patients only. For private insurance, these rules do not necessarily apply, and each will have its own rules.
The news rules will allow for direct payments to PAs for services provided. Often confused with billing, payments are a different topic. Services should usually be billed under the PA unless it is part of a split/shared visit or incident-to visit. Before this rule change, the only way a PA could receive payment was through their employer. In most cases, this will continue. However, this does give PAs the option to receive direct payments in the same manner NPs and physicians have been able to. Direct billing for PAs is a part of Optimal Team Practice (OTP) and has been something that the AAPA has been advocating.
Another change will be the rules for split/shared visits, and starting January 1, 2022, critical care services and certain visits in skilled and non-skilled nursing facilities will now be eligible for split (or shared) billing. Split/shared visits are medicare rules that apply to billing in an inpatient environment. A shared visit in an outpatient setting is referred to as incident-to, and has specific rules for these types of services to be billed:
Split/Shared Services – https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf
A split/shared service is an encounter where a physician and an NPP each personally perform a portion of an
E/M visit. Here are the rules for reporting split/shared E/M services between physicians and NPPs:
● In the office or clinic setting:
• For encounters with established patients who meet incident-to requirements, use either practitioner’s
National Provider Identifier (NPI)
• For encounters that do not meet incident-to requirements, use the NPP’s NPI
● Hospital inpatient, outpatient, and ED setting encounters shared between a physician and an NPP from
the same group practice:
• When the physician provides any face-to-face portion of the encounter, use either provider’s NPI
• When the physician does not provide a face-to-face encounter, use the NPP’s NPI
These visits require extra documentation by the supervising physician and usually is an ineffective use of time.
Most PAs do not fully understand the ins and outs of billing and reimbursement, but it is an aspect of the job they should learn. From a legal perspective, PAs should understand these rules, but also it can help demonstrate the monetary value that they bring to an organization.
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