Since January 1, 1987, PAs have been covered under Medicare Part B for services provided to Medicare beneficiaries in all hospital practices, including inpatient, outpatient, and emergency settings. Medicare will generally reimburse for any professional service performed by a physician assistant for which they would reimburse a physician.
In the past, Medicare gave hospitals two options for covering services provided by hospital-employed PAs. Services provided by PAs could be billed under Medicare Part B as a professional service, or the PA's salary could be included in the hospital's cost reports and covered under Medicare Part A. However, because of Medicare's shift to prospective payments, the option of including the PA's salary in the hospital's cost reports is no longer an appropriate method of coverage. 42CFR 409.10(b)(4)
Supervision
Medicare follows regulations established in each state regarding the degree of physician supervision required in hospitals. The physician supervisor need not be physically present with the PA in the hospital when a service is being furnished to a Medicare patient unless on-site supervision is required by state law or by the hospital's bylaws. If the physician supervisor (or physician designee) is not physically present with the PA, he or she must be immediately available to the PA for consultation purposes by telephone or other effective reliable means of communication.
Additional Regulatory Information
PAs practicing in hospitals should be aware of the "Medicare Conditions of Participation for Hospitals", also known as "CoPs". In order to receive Medicare or Medicaid payments, hospitals must certify that they have met the standards set forth in the CoPs. Most of the federal CoPs apply broadly to hospital conditions, fire safety, infection control, privacy rights and record keeping. However, there are a few areas that directly impact the ability of the physician-PA team to effectively care for patients. The AAPA manual, Physician Assistants & Hospital Practice, provides in-depth information on the CoPs and other regulatory documents affecting PA practice.
Reimbursement for Services Provided in the Hospital Setting
Claims for reimbursement should be submitted with the PA's NPI number and will be reimbursed at 85 percent of the physician fee schedule, as specified in the Balanced Budget Act of 1997, unless the shared visit billing exception applies.
Billing Consultations in the Hospital Setting
According to Medicare, PAs may request and perform consultations (as defined in the Medicare Claims Processing Manual, Chapter 12, 30.6.10 ) consistent with state law guidelines, hospital bylaws or rules and regulations. If the PA is employed by the hospital, the hospital would bill for the PA's service, when allowable. If the PA is employed by a physician or group, the physician or group would bill for the PA's service.
In 2005, the rules changed for billing consultations in the hospital setting. (See Pub 100-04 Medicare Claims Processing Manual, Transmittal 788.)
Consultations are no longer eligible for split/shared visit billing. Therefore, consultations performed by PAs are billed under the PA's NPI, and reimbursed at the 85% rate. Report the Initial Inpatient Consultation codes (99251 - 99255) for an initial consultation in the inpatient hospital setting. Following the initial consultation service in the hospital setting, the follow-up visits shall be reported using the Subsequent Hospital Care codes (99231 - 99233) for the inpatient hospital setting.
Note: Be aware that there is an EMTALA policy affecting PAs and Consultations in the ED. While your patient may not be a Medicare patient, any institution participating in the Medicare program and receiving Medicare funding must comply with EMTALA. "The decision as to whether the on call physician responds in person or directs a non-physician practitioner (physician assistant, nurse practitioner, orthopedic tech) as his or her representative to present to the dedicated ED is made by the responsible on call physician." For EMTALA purposes, the physician would have to be called or contacted to delegate the Consultation to a PA.
