(Medicare Claims Processing Manual)

1. Teaching Physician Services that Meet the Requirement for Presence During the Key/Critical Portion of the Service   Claims for teaching physician services in compliance with the requirements outlined in sections 100.1 - 100.1.6 of this chapter must include a GC modifier for each service, unless the service is furnished under the primary care center exception described in section 100.1.1C (refer to number 2, below).  When a physician (or other appropriate billing provider) places the GC modifier on the claim, he/she is certifying that the teaching physician has complied with the requirements in sections 100.1 through 100.1.6.  2. Teaching Physician Services Under the Exception for E/M Services Furnished in Primary Care Centers   Teaching physicians who meet the requirements in section 100.1.1C of this chapter must provide their A/B MAC (B) with an attestation that they meet the requirements. Claims for services furnished by teaching physicians under the primary care center excepti on must include the GE modifier on the claim for each service furnished under the primary care center exception.   100.2 - Interns and Residents  (Rev. 1, 10- 01-03) B3-2020.8, B3- 8030  An attending physicians services to beneficiaries in a teaching setting are covered under the supplementary medical insurance program.  Many physicians rendering such services are on the faculty of a medical school or have arrangements with providers to s upervise and teach interns and residents.  Payment may be made for professional services to a beneficiary by an attending physician where the attending physician provides personal identifiable direction to interns or residents who are participating in th e care of this patient.   See the Medicare Benefit Policy Manual, Chapter 15, for services furnished by interns and residents within and outside the scope of an approved training program.  110 - Physician Assistant (PA) Services Payment Methodology (Rev. 2656, Issuance: 02- 07-13, Effective: 02- 19-13, Implementation: 02- 19-13)  See chapter 15, section 190 of the Medicare Benefit Policy Manual, pub. 100- 02, for coverage policy for physician assistant (PA) services.  Physician assistant services are paid at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule. There is a separate payment policy for paying for PA assistant -at-surgery services.  See section 110.2 of this chapter.   110.1 - Global Surgical Payments (Rev. 2656, Issuance: 02- 07-13, Effective: 02- 19-13, Implementation: 02- 19-13)  When a PA furnishes services to a patient during a global surgical period, A/B MACs (B) shall determine the level of PA involvement in furnishing part of the surgeons global surgical package consistent with their current practice for processing such claim s.  PA services furnished during a global surgical period shall be paid at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule.  Billing requirements and adjudication of claims requirements for global surgeries are under chapter 12, sections 40.2 and 40.4 of the Medicare Claims Processing Manual, pub. 100-04.  110.2 - Limitations for Assistant -at-Surgery Services Furnished by Physician Assistants  (Rev. 2656, Issuance: 02-07-13, Effective: 02- 19-13, Implementation: 02-19-13)  Medicare law at section 1833(a)(1)(O) of the Social Security Act authorizes payment for  services that a PA furnishes as an assistant -at-surgery.  Specifically, when a PA actively assists a physician in performing a surgical procedure and furnishes more than just ancillary services, the PAs services are eligible for payment as assistant -at-surgery services.  For additional policy requirements concerning assistant- at-surgery services furnished by physicians and nonphysician practitioners, see chapter 12, section 20.4.3 of the Medicare Claims Processing Manual, pub. 100-04.  The A/B MAC (B) shall pay covered PA assistant -at-surgery services at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule.  Since physicians are paid at 16 percent of the surgical payment amount under the Medicare Physician Fee Schedule for assistant -at-surgery services, the actual payment amount that PAs receive for assistant -at-surgery services is 13.6 percent of the amount paid to physicians.  The AS modifier must be reported on the claim form when billing PA assistant- at-surgery services.    110.3 - Outpatient Mental Health Treatment Limitation  (Rev. 2656, Issuance: 02-07-13, Effective: 02- 19-13, Implementation: 02-19-13)  In general, payment for covered PA services is made at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule.  The A/B MAC (B) must apply the outpatient mental health treatment limitation (the limitation) to all covered mental health therapeutic services furnished by PAs.   Refer to 210 below for a complete discussion of the limitation.   110.4 - PA Billing to the A/B MAC (B)  (Rev. 11288; Issued: 03-04- 22; Effective: 01 -01-22; Implementation: 02-15-22)  A. PA Identification   Effective January 1, 2022, PAs must have their own nonphysician practitioner national provider identification (NPI) number for billing purposes.  Specialty code 97 applies for PAs enrolled in Medicare.   B. Assignment Requirement   All claims for PA services must be made on an assignment basis.  If any person or entity (PA employer or, a provider/supplier for whom the PA furnishes services as an independent contractor) knowingly and willfully bills the beneficiary an amount in excess  of the appropriate coinsurance and deductible, the responsible party is subject to a civil monetary penalty not to exceed $2,000 for each such bill or request for payment.  120 - Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) Services Payment Methodology (Rev. 2656, Issuance: 02- 07-13, Effective: 02- 19-13, Implementation: 02- 19-13)  See chapter 15, sections 200 and 210 of the Medicare Benefit Policy Manual, pub. 100-02, for coverage policy for NP and CNS services.   A. General Payment   In general, NPs and CNSs are paid for covered services at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule.  There is a separate payment policy for paying for NP and CNS assis tant-at-surgery services.  See section 120.1 of this chapter.  B. Global Surgical Payments   When a NP or CNS furnish services to a patient during a global surgical period, A/B MACs (B) shall determine the level of NP or CNS involvement in furnishing part of the surgeons global surgical package consistent with their current practice for processing such claims.  NP or CNS services furnished during a global surgical period shall be paid at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule.  Billing requirements and adjudication of claims requirements for global surgeries are under chapter 12, sections 40.2 and 40.4 of the Medicare Claims Processing Manual, Pub. 100- 04.  120.1 - Limitations for Assistant -at-Surgery Services Furnished by Nurse Practitioners and Clinical Nurse Specialists  (Rev. 2656, Issuance: 02- 07-13, Effective: 02- 19-13, Implementation: 02- 19-13)  Medicare law at section 1833(a)(1)(O) of the Social Security Act authorizes payment for  services that NPs and CNSs furnish as an assistant -at-surgery.  Specifically, when a NP or CNS actively assists a physician in performing a surgical procedure and furnishes more than just ancillary services, the NPs and CNSs services are eligible for payment as assistant -at-surgery services.  For additional policy requirements concerning assistant -at-surgery services furnished by physicians and nonphysician practitioners, see chapter 12, section 20.4.3 of the Medicare Claims Processing Manual, Pub. 100- 04.  The A/B MAC (B) shall pay covered NP and CNS assistant- at-surgery services at 80 percent of the lesser of the actual charge or 85 percent of the 16 percent that a physician is paid under the Medicare Physician Fee Schedule.  Since physicians are paid at 16 percent of the surgical payment amount under the Medicare Physician Fee Schedule for assistant -at-surgery services, the actual payment amount that NPs and CNSs receive for assistant -at-surgery services is 13.6 percent of the amount paid to physicians.  Only the AS modifier must be reported on the claim form when a NP or CNS bills assistant -at-surgery services.  120.2 - Outpatient Mental Health Treatment Limitation  (Rev. 2656, Issuance: 02-07-13, Effective: 02- 19-13, Implementation: 02-19-13)  The A/B MAC (B) must apply the outpatient mental health treatment limitation (the limitation) to all covered mental health therapeutic services furnished by NPs and CNSs.  Refer to 210, below, for a discussion of the limitation.  120.3 - NP and CNS Billing to the A/B MAC (B)  (Rev. 2656, Issuance: 02-07-13, Effective: 02- 19-13, Implementation: 02-19-13)  A. NP and CNS Identification  NPs and CNSs must have their own nonphysician practitioner national provider identification (NPI) number for billing purposes.  NPs enrolling in Medicare use specialty code 50 and CNSs use specialty code 89.  B. Assignment Requirement   All claims for NP and CNS services must be made on an assignment basis.  Payment may be made directly to a NP or CNS for their professional services when furnished in collaboration with a physician.  If any person or entity (employer, NP or CNS) knowingly and willfully bills the beneficiary an amount in excess of the appropriate coinsurance and deductible, the responsible party is subject to a civil monetary penalty not to exceed $2,000 for each such bill or request for payment.  130 - Nurse -Midwife Services  (Rev. 1, 10-01-03)  B3-16004, 5257  See the Medicare Benefit Policy Manual, Chapter 15, for coverage policy for nurse-midwife services.   130.1 - Payment for Certified Nurse-Midwife Services  (Rev. 2024, Issued: 08- 06-10, Effective: 01-01-11, Implementation: 01-03-11)  Payment for certified nurse -midwife (CNM) services is made directly to CNMs for their professional services, and for services furnished incident to their professional services.  Also, CNMs are required to accept assigned payment for their services.  Accordingly, when CNMs bill for their services under specialty code 42, billing does not have to flow through a physician or facility unless the CNM reassigns their benefits to another billing entity.  For reassigned CNM services, the entity bills for CNM services using the specialty code 42 to signify that payment for CNM services is being claim ed.  Prior to December 31, 1991, Medicare Part B payment for CNM services was made at 80 percent of the lesser of the actual charge or, under a fee schedule that did not exceed 65 percent of the prevailing charge.  This payment methodology changed and effective  January 1, 1992, until December 31, 2010, payment for CNM services is made at 80 percent of the lesser of the actual charge, or 65 percent of the physician fee schedule amount for the same service performed by a physician.  However, effective on and after  January 1, 2011, payment for CNM services is made at 80 percent of the lesser of the actual charge, or 100 percent of the physician fee schedule amount for the same service performed by a physician.  Payment for covered drugs and biologicals furnished incident to CNMs services is made according to the Part B drug/biological payment methodology.  Covered clinical diagnostic lab services furnished by CNMs are paid according to the clinical diagnostic lab fee schedule.  Also, when CNMs furnish outpatient treatment services for mental illnesses, these services could be subject to the outpatient mental health treatment limitation (the limitation).  The appropriate percentage payment reduction under the limitation is applied first to the approved amount for the mental health treatment services before the actual payment amount is determined for the CNMs services.  Please refer to 210 of this manual to determine the appropriate percentage payment reduction under the limitation.   130.2 - Global Allowances  (Rev. 2024, Issued: 08- 06-10, Effective: 01 -01-11, Implementation: 01- 03-11)