CMS recently released rules changing the requirements for Medicare coverage of services furnished incident to a physician’s, NP’s, or PA’s services. Howard Sollins, Donna Senft and Susan Turner explain the effect of the changes.
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Nurses, nursing assistants and other staff provide essential services in a host of clinical settings. Their services are typically considered an overall expense of the practice location, whether in a physician office, hospital, or other setting. Medicare Part B reimburses for the services of physicians and various other types of advanced practice professionals such as nurse practitioners (“NP”) and physician assistants (“PA”). Medicare Part B also covers hospital outpatient services. This article focuses on one new element of those requirements.
The Medicare rules recognize that certain staff may perform a particular task that is covered by Medicare Part B even though it was not performed personally by the physician, NP or PA.1 However, the staff’s task must be “incident to” the services of the physician, NP or PA. Under 42 U.S.C. x 1395x(s)(2). Medicare Part B covers under (A) “services and supplies (including drugs and biologicals which are not usually selfadministered by the patient) furnished as an incident to a physician ’professional service, of kinds which are commonly furnished in physicians’ offices and are commonly either rendered without charge or included in the physicians’ bills (or would have been so included but for the application of section 1395we3b of this title). Under (B) Medicare covers “hospital services (including drugs and biologicals which are not usually self-administered by the patient) incident to physicians’ services rendered to outpatients and partial hospitalization services incident to such services. Under (K)(i) and (ii), the same provisions under (A) apply when services are provided that are incident to an NP or PA professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services.
Thus, “incident to” billing for the services of staff is subject to various requirements as to the setting, supervision and other requirements. These are detailed in Medicare regulations under 42 C.F.R., Section 410.26. For example, “incident to” billing is permitted where the staff provide a service that meets all other requirements and is provided in an office, but the same service is not billable when rendered at bedside in a skilled nursing facility. In a hospital setting, the Medicare coverage regulation governing services that are incident to a physician, NP or PA’s services is under 42 C.F.R., Section 410.27.