At-a-Glance Billing Guidelines


Enrollment Information | Provider Numbers/Credentialing | Types of Services Coverage | Reimbursement | Fee Schedules | Employment Requirements | Payment For Services | Collaboration/Supervision | Assistant-At-Surgery | Diagnostic Tests  


Enrollment Information

Medicare (Billing Option #1: Direct Billing by an NPP)
Novitas Solutions Inc.
Provider Enrollment
(855) 252-8782

Medicaid
Texas Medicaid & Healthcare Partnership
(800) 925-9126
www.tmhp.com
Texas Star Program:
(800) 964-2777

Commercial Plans
Contact Each Carrier Accordingly


Provider Numbers/ Credentialing

Medicare (Billing Option #1: Direct Billing by an NPP)
Provider Numbers are issued upon completion of enrollment online through Medicare's Provider Enrollment, Chain and Ownership System (PECOS) or the appropriate 855 application form.

Medicaid
Provider Numbers are issued upon completion of enrollment online through Medicaid's Provider Enrollment on the Portal (PEP) system or Texas Medicaid Provider Enrollment Application.  Please note, various other applicable forms apply. 
Generally a provider must first be a Medicare provider before becoming a Medicaid provider. The requirement can be waived for pediatric providers.

Commercial Plans
Commercial health plans will vary in this process.  Some carriers will have a credentialing process in place, while others will indicate to bill under the physicians name.  (Read contracts and/or call carriers.)


Types of Services/Coverage

Medicare (Billing Option #1: Direct Billing by an NPP)
Coverage is limited to the services an NP/CNS/PA is legally authorized to perform in accordance with state law.   Traditional examples of the types of services that these practitioners may provide include services such as physical exams, minor surgery, setting casts for simple fractures, interpreting X-rays, and other activities that involve an independent evaluation or treatment of the patients condition.

Services may be covered under Part B, if all the following are met:

  • They are the type that are considered physician's services if furnished by an MD or DO;
  • They are performed by a person who meets the definition of an NP/PA or qualifies as a CNS;
  • They are performed under the supervision of an MD/DO (for PA's only) or are performed in "collaboration" with an MD/DO (for NPs and CNS's only);
  • The practitioner is legally authorized to perform the services in the state in which they are performed; and,
  • They are not otherwise non-covered.

Medicaid
APN or PA services must be delivered according to protocols developed jointly with the physician, and must be in accordance with the scope of practice and state law governing APNs and PAs.

APNs - Services performed by APNs are covered if the services meet the following criteria:

  • Within the scope of practice for APNs, as defined by Texas state law;
  • Consistent with rules and regulations promulgated by the Board of Nurse Examiners for the State of Texas or other appropriate state licensing authority;
  • Covered by the Texas Medicaid Program when provided by a licensed physician (MD or DO); and,
  • Are reasonable and medically necessary as determined by HHSC or its designee.

APNs who are employed or remunerated by a physician, hospital, facility, or other provider must not bill for their services if that billing would result in duplicate payment for the same services.

Benefit limitation information for services may be found in the specific sections of the Texas Medicaid Provider Procedures Manual as listed below:

  • Physician Services
  • THSteps medical (included newborn exams)
  • Family Planning

Services performed by PAs are covered if the services meet the following criteria:

  • Within the scope of practice for PAs, as defined by Texas state law
  • Consistent with rules and regulations promulgated by the Texas State Medical Board or other appropriate state licensing authority
  • Covered by Texas Medicaid when provided by a licensed physician (MD or DO)
  • Are reasonable and medically necessary as determined by HHSC or its designee

APNs and PAs are encouraged to provide family planning services to Medicaid clients especially pregnant women and postpartum clients.  No separate enrollment is required. Refer to the Texas Medicaid Provider Procedures Manual for further information.

Commercial Plans
May vary from carrier to carrier. (Read contracts and/or call carriers.) 

Coverage should be consistent with scope of practice. 

HB 2846 (1997) prohibits insurers from discriminating against NPPs for providing covered services they are licensed to perform.


Reimbursement

Medicare (Billing Option #1: Direct Billing by an NPP)
85% of the Physician Fee Schedule amount.

Medicare assignment must be accepted on all claims submitted by Non-Physician practitioners.

Medicaid
NP/CNS - 92 percent of the rate paid to a physician (doctor of medicine [MD] or doctor of osteopathy [DO]) for the same service and 100 percent of the rate paid to physicians for laboratory services, x-ray services and injections.

PA - The Medicaid rate for PAs is 92 percent of the rate paid to a physician (doctor of medicine [MD] or doctor of osteopathy [DO]) for the same professional service and 100 percent of the rate paid to physicians for laboratory services, x-ray services and injections.

Services performed by a PA and billed under a physician's or rural health clinic's (RHC's) provider identifier are reimbursed according to the Texas Medicaid Reimbursement Methodology (TMRM) for physician services.

Commercial Plans
This will vary from carrier to carrier.  85% of the physician reimbursement would be likely should the carrier have a mechanism to pay claims in this manner. (Read contracts and/or call carriers.)


 Fee Schedules

Medicare (Billing Option #1: Direct Billing by an NPP)
A Fee Schedule may be obtained:

Medicaid
Fee schedules are available on the TMHP Web site at http://public.tmhp.com/FeeSchedules/Default.aspx  . To request a hard copy, call the TMHP Contact Center at (800) 925-9126. 

Commercial Plans
Contact each carrier accordingly.


 Employment Requirements

Medicare (Billing Option #1: Direct Billing by an NPP)
NP/CNS - May be employed or self employed.

PA - Must be employed. The employer may be a:

  • physician;
  • medical group;
  • professional corporation;
  • hospital;
  • Skilled Nursing Facility (SNF); or,
  • Nursing Facility (NF).
     

There must be a valid employment arrangement (common law employee-employer relationship).

Medicaid
APN- May be employed or self employed.

PA - May be employed or self employed.

Commercial Plans
Will vary from carrier to carrier. (Read contracts and/or call carriers.)


Payment For Services

Medicare (Billing Option #1: Direct Billing by an NPP)
NP/CNS- If employed, payment will be made to the employer.  If self employed, payment will be made directly to the NP/CNS.

PA - Payment for services may be made only to the actual employer of the PA.

Medicaid
APN- If employed, payment will be made to the employer.  If self employed, payment will be made directly to the APN.

PA - If employed, payment will be made to the employer. If self-employed, payment will be made directly to the PA. 

Commercial Plans
Will vary from carrier to carrier. (Read contracts and/or call carriers.)


 

Collaboration/ Supervision

Medicare (Billing Option #1: Direct Billing by an NPP)
NP/CNS- Must provide services in "collaboration" with a physician.  "Collaboration" means a process whereby an NP/CNS works with a physician to deliver health care services within the scope of the NP/CNS's professional expertise with medical direction and appropriate supervision as provided for in jointly-developed guidelines or other mechanisms defined by federal regulation and the law of the state in which the services are performed.  There must be a written agreement between the collaborating physician and NP/CNS for services provided by the NP/CNS and it must be made available to Medicare upon request.  Any services not in the agreement cannot be billed to the Medicare program.

PA - Services must be provided under the supervision of a physician.  The PA's physician supervisor is primarily responsible for: 

  • the overall direction and management of the PA's professional services; and,
  • for assuring that the services provided are medically appropriate for the patient.

The physician supervisor: 

  • Need not be physically present with the PA;
  • Must be immediately available to the PA for consultation purposes by telephone or other effective, reliable means of communication.  

Medicaid
APNs and PAs no longer require personal supervision as long as the services are delivered according to protocols developed jointly with a physician and in accordance with the scope of practice and state law governing APNs and PAs.

Commercial Plans
Will vary from carrier to carrier. (Read contracts and/or call carriers.)


Assistant-At-Surgery

Medicare (Billing Option #1: Direct Billing by an NPP)
NP/CNS/PA's may be paid for an assistant-at-surgery when the procedure is covered for an assistant.

Modifier -AS should be applied to surgical CPT codes to indicate the charge is for the assistant-at-surgery.

Medicaid
APN/PA's may be paid for an assistant-at-surgery when the procedure is covered for an assistant. The most appropriate assistant surgeon modifier should be billed when billing for assistant at surgery services. For assistant surgical procedures, one of the following modifiers should be billed: 80, 81, 82 or AS. Please see the information below for additional requirements for PAs.

PA - PAs functioning as an assistant during surgery should be billed on the same claim as the surgery when the PA is not separately enrolled as a provider. Supervising physicians as defined by the Texas Medical Board may bill Medicaid for services performed by the PA they supervise. Use modifier AS for assistant at surgery services rendered by the PA. The claim must include the PA's name and license number.

PAs actively enrolled as a Medicaid provider with an assigned provider identifier may bill assistant surgery services on a separate claim form using the PA's individual provider identifier and modifiers U7 and 80.

To determine if a surgery is payable for a specific provider type, refer to the appropriate fee schedule on the TMHP Web site at http://public.tmhp.com/FeeSchedules/Default.aspx. In addition, refer to the Texas Medicaid Provider Procedures Manual to verify the complete list of modifiers recognized by Texas Medicaid.

Commercial Plans
Will vary from carrier to carrier. (Read contracts and/or call carriers.)

Coverage should be consistent with scope of practice. 

HB 2846 (1997) prohibits insurers from discriminating against NPPs for providing covered services they are licensed to perform.


Diagnostic Tests

Medicare (Billing Option #1: Direct Billing by an NPP)
Medicare will allow NP/CNS/PA's to perform diagnostic services as allowed under state law.

Medicare will not however, allow the practitioners to serve as the supervising physician for an independent diagnostic testing facility.

Medicaid
Medicaid will allow APN/PA's to perform diagnostic services as allowed under state law.

Commercial Plans
Will vary from carrier to carrier. (Read contracts and/or call carriers.) 

Coverage should be consistent with scope of practice. 

HB 2846 (1997) prohibits insurers from discriminating against NPPs for providing covered services they are licensed to perform.

Incident to Billing Criteria (Medicare Option#2)  


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