- Evaluation and Management Services
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FAQs
- Admission and Discharge Services
- Advanced Care Planning
- Behavioral/Mental Health Services
- Chronic Care Management
- Complex and Chronic Care - HCPCS Code G2211
- Consultations
- Critical Care Services
- Documentation
- Emergency Department
- Examination
- Fee-For-Time Compensation Arrangements
- General E/M Information
- Global Period Services
- History
- IPPE and AWV Services
- Medical Decision Making
- New vs. Established Patients
- Nonphysician Practitioner Services
- Observation Services
- Preoperative Clearance
- Prolonged Services
- Provider Specialty
- Scribes
- Separately Identifiable Service
- Skilled Nursing Facility Services
- Smoking Cessation
- Split/Shared and Incident To Services
- Teaching Environment E/M Services
- Telehealth Services
- Time-Based Services
- Transitional Care Management
- Urgent Care
- Related Articles
Nonphysician Practitioner Services
In addition to the frequently asked questions below, please view NGS’ Nonphysician Practitioners-Reducing Costly Appeals; Increase Provider Revenue article for related information.
- Is it permissible for an NPP to perform an initial hospital admission or discharge service on behalf of the attending physician, or on a split/shared basis, when both are members of the same provider group?
Answer: The physician who is serving as the attending/admitting provider is responsible for the initial hospital visit (CPTs 99221-99223) on admission. The service may be split/shared between the attending physician and a NPP member of the group, with each provider documenting his/her contribution to the service. In these instances, the attending physician must fulfill the role of the substantive/billing provider and add Modifier AI to the service on the claim. NPP claims with Modifier AI will not be processed for payment. The attending physician is also responsible for the discharge service, which may also be performed on a split/shared basis.
- Is more than one E/M service by a PA (Specialty 97) or NP (Specialty 50) payable on the same DOS?
Answer: CMS permits one E/M service per beneficiary, per day, per provider specialty type. Since PAs and NPs often provide specialty care (e.g., family practice, psychiatry, orthopedics), multiple E/M services on the same DOS may be permissible, when each episode of care is addressing a different clinical condition in a different sub-specialty area.
- In the office setting, can more than one new patient visit by a PA (Specialty 97) or NP (Specialty 50) be paid within a three-year period?
Answer: In the office setting, CMS permits one new patient visit per beneficiary per three-year period for providers of the same specialty in a group practice. When a NPP (PA or NP) adds the physician specialty information to the 2300/2400 STE Segment Loop (or Box 19) of each claim, this allows National Government Services to compare the previously paid new visit claim with the currently pending new visit claim. If the supervising physician specialties on the two claims are different (e.g., orthopedics vs. psychiatry) then the second new patient visit may be allowed to process.
- What are the NGS suggestions for submitting NP and PA claims for E/M services?
Answer:We have instructed NP and PA providers to include additional information on all of their E/M claims, defining the specialty of the physician group in which the care was rendered. When this information is identified on a claim, the claim suspends for examiner review; the examiner compares the information on the paid history claim with the information on the claim now pending.
- How do NP and PA providers include supervising specialty information on their claims?
Answer: This information is to be included in the 2300 NTE Loop Segment on electronic claims or in box 19 on paper claims. The claims are to be submitted with either NP (Specialty 50) or PA (Specialty 97) as the rendering provider as usual, with this additional information entered separately, describing the specialty of the physician practice in which the care was rendered.
- Where can a list of CMS provider specialty designations be located?
Answer: Medicare Provider Specialty Codes are available in the Enrollment section of our website.
- How will NGS be processing these NP and PA E/M claims?
Answer: The first E/M claim from an NP or PA on a DOS will process as usual; however, subsequent NP and PA claims on that DOS will be suspended for review of the physician specialty group information and a comparison of the diagnoses on the paid claim vs. any subsequent claim. When both the physician specialty information and the diagnosis on the two claims are different, the second claim may be payable.
- Please define the diagnosis requirements for these claims.
Answer: When claims for services by multiple NPs and PAs on the same DOS are received, the diagnosis on each of these claims will be compared with any other paid E/M claims on that DOS. If an E/M claim has already been paid to an NP or PA for treatment of a particular diagnosis, any subsequent claims with that same diagnosis will be denied.
- In a specialty group, will two E/M claims with the same diagnosis be payable, if they are submitted by a physician and also an NP or PA in that group?
Answer: In a group practice, it is not permissible to submit two separate E/M claims for care rendered by both a physician and an NP or PA that addresses the same clinical problem. For example: an NP elicits a patient history and decides to request a physician’s participation in the care. In this scenario, care rendered by the two practitioners is combined in level-setting the visit, but only one visit is billable to Medicare.
- If an NP or PA E/M claim is missing the physician group specialty information, will it still be considered for payment?
Answer: As above, the initial E/M service may be payable; subsequent same-specialty E/M services on that same DOS will be denied if the physician group specialty information is missing from either the paid history claim or the claim now pending. This denial may be appealed via the standard appeal process.
- Do all NPs and PAs have to comply with these new billing instructions?
Answer: This is a voluntary but highly recommended process, designed to decrease the administrative burden associated with these claims. NGS encourages all NPs and PAs to initiate this change as soon as possible.
- How does this change impact independent NP groups?
Answer: This will not permit multiple E/M services within the NP group on the same DOS (since the NP specialty will be the same), but will permit comparison with another NP service on that date, performed within a different specialty group environment and addressing a different clinical condition.
- If a NP or PA E/M service is denied, what are the options for appeal?
Answer: Denied NP or PA E/M services are still subject to the standard appeal process.
- Please define the reason code that is associated with denials for multiple NP or PA services on the same DOS.
Answer: The reason code associated with denials for multiple NP or PA services on the same DOS is N20.
- Please define the reason code associated with denials for multiple NP or PA new patient services within a three- year period.
Answer: The reason code associated with denials for more than one new patient visit in a three-year period is M13.
Reviewed 10/8/2024