Physician Assistants (PAs)

For information how to enroll in Medicare, visit Advanced Practice Nonphysician Practitioners.

You must be a licensed physician assistant (PA) by the state where you practice and have completed 1 of these:

• Graduated from a PA educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant or its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs and Committee on Allied Health Education and Accreditation

• Passed the national certification exam administered by the National Commission on Certification of Physician Assistants

 You must meet these requirements:

• You’re legally authorized to practice medicine in the state where you furnish the services.
• The services are reasonable and necessary.
• The services are what we consider physician services if a medical doctor or Doctor of Osteopathy provided them. Physician services include professional patient services a physician performs, including diagnosis, therapy, surgery, consultation, and care plan oversight.
• You must provide services under physician supervision.

• We cover services only when furnished according to state law and scope-of-practice rules. You have flexibility to meet the statutory physician supervision requirement in collaboration with physicians and forming partnerships if it’s according to your state scope of practice laws.
• You may provide assistant-at-surgery services.
• Auxiliary personnel may have services and supplies provided incident to your own professional services.
• You may certify patient-eligibility under the Medicare home health benefit and oversee their plan of care. You may bill HCPCS codes G0179, G0180, and G0181.
• You may review and verify (sign and date), rather than re-document, notes in a patient’s medical record, including documentation of your presence and service participation, made by:

  • Physicians

  • Residents

  • Nurses

  • Medical, PA, or advanced practice registered nurse students

  • Other medical team members

• You may:

  • Use your NPI to bill your services

  • Let an employer or contractor use your NPI to bill your reassigned services

• For services you provided before January 1, 2022:

  • We paid your employer for your services under employment or contractor relationship

  • You couldn’t reassign payment for your services, and your employer or contractor couldn’t bill reassigned services

  • You couldn’t bill under your NPI for services auxiliary personnel provided incident to your professional services

• We apply reasonable and necessary standards to each service you bill. This limits our payments to covered services that address and treat patient complaints and symptoms. Services must meet specific medical necessity statutes, regulations, manual requirements, National Coverage Determinations, and Local Coverage Determinations. For each billed service, note specific signs, symptoms, or patient complaints that make each service reasonable and necessary.

• We pay only on an assignment basis.
• You can’t charge a patient more than the amounts permitted under 42 CFR 424.55. If a patient pays more for a service than the assignment payment limits, you must refund the excess amount.
• We pay services at 80% of the lesser of the actual amount or 85% of the amount a physician gets under the Physician Fee Schedule (PFS) when provided outside a hospital or skilled nursing facility (SNF) setting.

• We pay you only if no facility or other provider charges, or we didn’t pay any other service amount they provided.

• We pay you directly for assistant-at-surgery services at 85% of 16% of the amount a physician gets under the PFS.

• When you bill your services in the hospital setting (inpatient and outpatient), we unbundle the payment and pay you directly under the PFS.

• We pay your professional services only when:

  • You personally perform the services

  • There aren’t any facility or other provider charges for the services

• Services, billing, and payment information:

  • Medicare Benefit Policy Manual, Chapter 15, section 190

  • Medicare Claims Processing Manual, Chapter 12, section 110

• Qualifications: 42 CFR 410.74