Transmittal 1744 Date: MARCH 12, HEADER SECTION NUMBERS PAGES TO INSERT PAGES TO DELETE (4 pp.) (4 pp.

Transcription

1 Medicare Carriers Manual Department f Health & Human Services (DHHS) Centers fr Medicare & Medicaid Services (CMS) Part 3 - Claims Prcess Transmittal 1744 Date: MARCH 12, 2002 CHANGE REQUEST 2068 HEADER SECTION NUMBERS PAGES TO INSERT PAGES TO DELETE (4 pp.) (4 pp.) NEW/REVISED MATERIAL--EFFECTIVE DATE: April 1, 2002 IMPLEMENTATION DATE: April 1, 2002 Sectin 2156, Physician Assistant Services, is being revised t update the physician assistant (PA) qualificatins t recgnize a name change f the accrediting bdy that accredits PA educatinal prgrams. Revisins have been made t the Emplyment Relatinship sectin f this instructin t allw a prfessinal crpratin that permits PA wnership in the crpratin t bill the prgram fr PA services prviding the prfessinal crpratin is duly authrized and licensed under State laws and regulatins. Additinally, the sentence under this sectin f the instructin that precluded ASCs frm being cnsidered as an apprpriate emplyer f a PA has been remved. DISCLAIMER: The revisin date and transmittal number nly applies t the redlined material. All ther material was previusly published in the manual and is nly being reprinted. These instructins shuld be implemented within yur current perating budget. CMS-Pub. 14-3

2 03-02 COVERAGE AND LIMITATIONS NURSE-MIDWIFE SERVICES A. General.--Effective n r after July 1, 1988, the services prvided by a certified nursemidwife r incident t the certified nurse-midwife's services are cvered. Payment is made nly under assignment. See 5257 fr payment guidelines. B. Certified Nurse-Midwife Defined.--A certified nurse-midwife is a registered nurse wh has successfully cmpleted a prgram f study and clinical experience in nurse-midwifery, meeting guidelines prescribed by the Secretary, r wh has been certified by an rganizatin recgnized by the Secretary. The Secretary has recgnized certificatin by the American Cllege f Nurse- Midwives and State qualifying requirements in thse States that specify a prgram f educatin and clinical experience fr nurse-midwives fr these purpses. A nurse-midwife must: Be currently licensed t practice in the State as a registered prfessinal nurse; and Meet ne f the fllwing requirements: - Be legally authrized under State law r regulatins t practice as a nursemidwife and have cmpleted a prgram f study and clinical experience fr nurse-midwives, as specified by the State; r - If the State des nt specify a prgram f study and clinical experience that nurse-midwives must cmplete t practice in that State, the nurse-midwife must: Nurse-Midwives; + Be currently certified as a nurse-midwife by the American Cllege f + Have satisfactrily cmpleted a frmal educatin prgram (f at least ne academic year) that, upn cmpletin, qualifies the nurse t take the certificatin examinatin ffered by the American Cllege f Nurse-Midwives; r + Have successfully cmpleted a frmal educatin prgram fr preparing registered nurses t furnish gyneclgical and bstetrical care t wmen during pregnancy, delivery, and the pst partum perid, and care t nrmal newbrns, and have practiced as a nurse-midwife fr a ttal f 12 mnths during any 18-mnth perid frm August 8, 1976, t July 16, C. Cvered Services General.--Effective January 1, 1988, thrugh December 31, 1993, the cverage f nurse-midwife services was restricted t the maternity cycle. The maternity cycle is a perid that includes pregnancy, labr, and the immediate pst partum perid. Beginning with services furnished n r after January 1, 1994, cverage is n lnger limited t the maternity cycle. Cverage is available fr services furnished by a nurse-midwife that he r she is legally authrized t perfrm in the State in which the services are furnished and that wuld therwise be cvered if furnished by a physician, including bstetrical and gyneclgical services. 2. Incident T.--Services and supplies furnished incident t a nurse midwife's service are cvered if they wuld have been cvered when furnished incident t the services f a dctr f medicine r stepathy, as described in Rev

3 2154 (Cnt.) COVERAGE AND LIMITATIONS D. Nncvered Services.--The services f nurse-midwives are nt cvered if they are therwise excluded frm Medicare cverage even thugh a nurse-midwife is authrized by State law t perfrm them. Fr example, the Medicare prgram excludes frm cverage rutine physical checkups and services that are nt reasnable and necessary fr the diagnsis r treatment f an illness r injury r t imprve the functining f a malfrmed bdy member. Cverage f service t the newbrn cntinues nly t the pint that the newbrn is r wuld nrmally be treated medically as a separate individual. Items and services furnished the newbrn frm that pint are nt cvered n the basis f the mther's eligibility. E. Relatinship With Physician.--Mst States have licensure and ther requirements applicable t nurse-midwives. Fr example, sme require that the nurse-midwife have an arrangement with a physician fr the referral f the patient in the event a prblem develps that requires medical attentin. Others may require that the nurse-midwife functin under the general supervisin f a physician. Althugh these and similar State requirements must be met in rder fr the nurse-midwife t prvide Medicare cvered care, they have n effect n the nurse-midwife's right t persnally bill fr and receive direct Medicare payment. That is, billing des nt have t flw thrugh a physician r facility. See fr cverage f services perfrmed by nurse-midwives incident t the service f physicians. F. Place f Service.--There is n restrictin n place f service. Therefre, nurse-midwife services are cvered if prvided in the nurse-midwife's ffice, in the patient's hme, r in a hspital r ther facility, such as a clinic r birthing center wned r perated by a nurse-midwife PHYSICIAN ASSISTANT SERVICES Effective fr services rendered n r after January 1, 1998, any individual wh is participating under the Medicare prgram as a physician assistant fr the first time ever, may have his r her prfessinal services cvered if he r she meets the qualificatins listed belw, and he r she is legally authrized t furnish PA services in the State where the services are perfrmed. PAs wh were issued billing prvider numbers prir t January 1, 1998, may cntinue t furnish services under the PA benefit. Payment fr PA services is effective n the date f services, that is, n r after January 1, 1998, and payment is made n an assignment-related basis nly. A. Qualificatins fr PAs.--In rder t furnish cvered PA services, the PA must meet the cnditins as fllws: 1. Have graduated frm a physician assistant educatinal prgram that is accredited by the Accreditatin Review Cmmissin n Educatin fr the Physician Assistant (its predecessr agencies, the Cmmissin n Accreditatin f Allied Health Educatin Prgrams (CAAHEP) and the Cmmittee n Allied Health Educatin and Accreditatin (CAHEA); r 2. Have passed the natinal certificatin examinatin that is administered by the Natinal Cmmissin n Certificatin f Physician Assistants (NCCPA); and 3. Be licensed by the State t practice as a physician assistant Rev. 1744

4 03-02 COVERAGE AND LIMITATIONS 2156 (Cnt.) B. Cvered Services.--Cverage is limited t the services a PA is legally authrized t perfrm in accrdance with State law (r State regulatry mechanism prvided by State law). 1. General.--The services f a PA may be cvered under Part B, if all f the fllwing requirements are met: They are the types f services that are cnsidered physician's services if furnished by a dctr f medicine r stepathy (MD/DO); The services are perfrmed by a persn wh meets all f the PA qualificatins (see subsectin A); and are perfrmed; subsectin C) and The PA is legally authrized t perfrm the services in the State in which they The services are perfrmed under the general supervisin f a MD/DO (see The services are nt therwise precluded frm cverage because f ne f the statutry exclusins. (See subsectin B.4.) 2. Types f PA Services That May Be Cvered.--State law r regulatins gverning a PA s scpe f practice in the State where the services are perfrmed applies. Cnsider develping lists f cvered services based n State scpe f practice. Examples f the types f services that PAs may furnish include services that traditinally have been reserved t physicians, such as physical examinatins, minr surgery, setting casts fr simple fractures, interpreting x-rays, and ther activities that invlve an independent evaluatin r treatment f the patient s cnditin. Als, if authrized under the scpe f their State license, PAs may furnish services billed under all levels f CPT evaluatin and management cdes, and diagnstic tests if furnished under the general supervisin f a physician. 3. Incident T.--If cvered PA services are furnished, services and supplies furnished incident t the PA's services may als be cvered if they wuld have been cvered when furnished incident t the services f an MD/DO, as described in See fr cverage f services perfrmed by PAs incident t the services f physicians. 4. Services Otherwise Excluded Frm Cverage.--PA services may nt be cvered if they are therwise excluded frm cverage even thugh a PA may be authrized by State law t perfrm them. Fr example, the Medicare law excludes frm cverage rutine ft care and, rutine physical checkups, and services that are nt reasnable and necessary fr the diagnsis r treatment f an illness r injury r t imprve the functining f a malfrmed bdy member. Therefre, these services are precluded frm cverage even thugh they may be within a PA's scpe f practice under State law. C. Physician Supervisin.--The PA's physician supervisr (r a physician designated by the supervising physician r emplyer as prvided under State law r regulatins) is primarily respnsible fr the verall directin and management f the PA's prfessinal activities and fr assuring that the services prvided are medically apprpriate fr the patient. The physician supervisr (r physician designee) need nt be physically present with the PA when a service is being furnished t a patient and may be cntacted by telephne if necessary, unless State law r regulatins require therwise. Rev

5 2158 COVERAGE AND LIMITATIONS D. Emplyment Relatinship.-- Payment fr services f a PA may be made nly t the actual qualified emplyer f the PA that is eligible t enrll in the Medicare prgram under existing Medicare prvider/supplier categries. If the emplyer f the PA is a prfessinal crpratin r ther duly qualified legal entity (such as a limited liability cmpany r a limited liability partnership), prperly frmed, authrized and licensed under State laws and regulatins, that permits PA wnership in such crpratin r entity as a stckhlder r member, that crpratin r entity as the emplyer may bill fr PA services even if a PA is a stckhlder r fficer f the entity, as lng as the entity is entitled t enrll as a prvider f services r a supplier f services in the Medicare prgram. PAs may nt therwise rganize r incrprate and bill fr their services directly t the Medicare prgram, including as, but nt limited t as sle prprietrships r general partnerships. Accrdingly, a qualified emplyer is nt a grup f PAs that incrprate t bill fr their services. Leasing agencies and staffing cmpanies d nt qualify under the Medicare prgram as prviders f services r suppliers f services. (See 4112 fr billing instructins.) NURSE PRACTITIONER SERVICES Effective fr services rendered after January 1, 1998, any individual wh is participating under the Medicare prgram as a nurse practitiner (NP) fr the first time ever, may have his r her prfessinal services cvered if he r she meets the qualificatins listed belw, and he r she is legally authrized t furnish NP services in the State where the services are perfrmed. NPs wh were issued billing prvider numbers prir t January 1, 1998 may cntinue t furnish services under the NP benefit. Payment fr NP services is effective n the date f service, that is, n r after January 1, 1998, and payment is made n an assignment-related basis nly. A. Qualificatins fr NPs.-- In rder t furnish cvered NP services, a NP must meet the cnditins as fllws: 1. Be a registered prfessinal nurse wh is authrized by the State in which the services are furnished t practice as a nurse practitiner in accrdance with State law; and - Be certified as a nurse practitiner by a recgnized natinal certifying bdy that has established standards fr nurse practitiners; r 2. Be a registered prfessinal nurse wh is authrized by the State in which the services are furnished t practice as a nurse practitiner by December 31, The fllwing rganizatins are recgnized natinal certifying bdies: American Academy f Nurse Practitiners; American Nurses Credentialing Center; Natinal Certificatin Crpratin fr Obstetric, Gyneclgic and Nenatal Nursing Specialties; Rev. 1744