The key to accurate interpretation of payment policy is identifying in which setting, SNF or NF, the physician services are being provided. Inaccurate interpretation of these regulations may affect compliance, and may also affect payment to providers
Physicians managing patient care in nursing facilities and skilled nursing facilities may delegate visits to PAs. In skilled nursing facilities, services assigned to a physician (such as the initial comprehensive visit) must be performed by a physician and not delegated to a PA. If allowed by state law, Medicare allows PAs practicing in nursing facilities to provide services that are designated as physician services, as long as they are not employed by the facility. Additionally, Medicare regulations dictate that nursing home patients be seen at least once every 30 days for the first 90 days of care and every 60 days thereafter. Of these visits, a physician and a PA may alternate visits and a PA may perform any necessary unscheduled visits without disrupting the established alternating visit pattern. [42 CFR, § 483.40]
On November 13, 2003, CMS issued the Survey & Certification letter (S&C-04-08), which addresses the differences in requirements concerning the delegation of physician tasks in Skilled Nursing Facilities(SNFs) and Nursing Facilities (NFs) from a survey and certification perspective. The letter can be downloaded from the CMS website, and includes the table below.
Table 1: Authority for Non-physician Practitioners to Perform Visits, Sign Orders and Sign Certifications/Recertifications When Permitted by the State*
|
|
Initial Comprehensive Visit / Orders |
Other Required Visits^ |
Other Medically Necessary Visits & Orders+ |
Certification/Recertification
|
|
SNFs |
|
|
|
|
|
NP & CNS employed by the facility |
May not perform/May not sign |
May perform |
May perform and sign |
May not sign |
|
NP & CNS not a facility employee |
May not perform/May not sign |
May perform |
May perform and sign |
May sign subject to State Requirements |
|
PA regardless of employer |
May not perform/ May not sign |
May perform |
May perform and sign |
May not sign |
|
NFs |
|
|
|
|
|
NP, CNS & PA employed by the facility |
May not perform/May not sign |
May not perform |
May perform and sign |
May sign subject to State Requirements |
|
NP, CNS & PA not a facility employee |
May perform/ May sign |
May perform |
May perform and sign |
May sign subject to State Requirements |
|
|
*This reflects clinical practice guidelines
^Other required visits are the required monthly visits that may be alternated between physician and non-physician practitioner after the initial comprehensive visit is completed
+Medically necessary visits may be performed prior to the initial comprehensive visit
Source: http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter04-08.pdf,
For more information on non-physician practitioners providing services in skilled nursing facilities and nursing facilities, see the Medicare Learning Network publication, Medlearn Matters SE0418.
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0419.pdf.
