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Mid Level Provider Questions and Answers

Mid level provider and 97597/97598

Question: Can a mid level provider such as a nurse practitioner, physician assistant, clinical nurse specialist, or certified nurse midwife perform the wound care procedure codes 97597 and 97598?

Answer: A mid level provider may perform these services. WPS GHA is not denying these services when performed by a mid level provider.

Mid Level providers and Provider Based Clinics

Question: We are a provider based clinic (PBC) and submit our charges using place of service (POS) code 22. Can we bill under the incident to provisions for services provided by ancillary staff or mid level providers?

Answer: No. Services provided in a POS other than office (11) or home (12) do not meet the incident to guidelines as described in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Chapter 15, Section 60.1.A. Services provided by mid level providers (physician assistant, nurse practitioner, clinical nurse specialist, certified nurse midwife) may be billed to Medicare Part B under his/her provider number. Services provided by ancillary staff are not billed to Medicare Part B using the 1500 form or the electronic equivalent. Instead, the facility includes those charges in their bill submitted on the UB form.

For those providers who have submitted charges and received payment under the MD/DO provider number for services provided by the mid level providers should determine the difference in rates and refund Medicare.

Mid Level providers and time

Question: How does time and evaluation and management (E/M) apply when the services are provided by a mid level provider or by both a mid level provider and the MD/DO as a shared/split visit?

Answer: A MD/DO providing the service can use time to choose the procedure code. A mid level providing the service can use time to choose the procedure code. Time cannot choose the procedure code when the service is a shared/split service between the MD/DO and mid level provider. When using time to choose a level of procedure code, the counseling/coordination of care guidelines must be met. Part of this guideline is that the counseling/coordination of care is more than 50% of the face-to-face time spent with the physician. This is reflected in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6.1.C.

Mid Level providers and Locum Tenens

Question: We have a mid level provider who is going on maternity leave. Can we use and bill for a locum tenens mid level provider while she is gone?

Answer: Locum tenens and reciprocal billing is only available for MD/DO. If you are hiring a temporary replacement for your mid level provider you will need to enroll the new person with Medicare. You can find more information in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Chapter 1, Section 30.2.11.

Mid Level providers and Appropriate Billing

Question: Our MD/DO saw the patient 2 years ago. The patient is now coming for services by the physician assistant (PA.) Is it appropriate to bill these evaluation and management services (E/M) as a new patient or should I submit the services as a subsequent patient. The services are not part of the plan of care from two years ago.

Answer: Medicare rules state that a patient is considered new when there has been no face-to-face encounter with the same physician or a member of the same group with the same specialty in the previous three years. You can bill the service as a new patient under the PA provider number as long as no other PA in your group has billed an initial visit. The MD/DO and mid level provider are different specialties. Medicare enrolls a mid level based on their designation, such as physician assistant (97), rather than the clinical area to which they have specialized.

Mid Level providers and Dermatology

Question: We are a dermatology office. The MD/DO saw the patient for the removal of actinic keratosis (AK) approximately 3 months ago. The physician assistant is now seeing the patient for a new area of AK. Since we are performing the same treatment, can we bill this under the incident to guidelines and receive the MD/DO reimbursement?

Answer: No, the MD/DO has not seen the patient for the new lesion and therefore would not have set the plan of care. Submit these charges under the mid level provider number.

Mid Level providers and Radiology Supervision

Question: The mid level provider is the only clinician in the office today. She orders a chest x-ray for the patient and this is performed by the technician in our office. Can we bill the technical component of the x-ray under the mid level provider number?

Answer: No. Mid level providers cannot supervise diagnostic tests. They can order a diagnostic test, they can perform the technical component acting as the technician, they can provide the professional component in performing the interpretation and report, but they cannot supervise a technician performing the service. In the example given, if the supervision requirements are met, the technical portion of the diagnosis test can be billed under the MD/DO.