Effective for services rendered on or after January 1, 1998, any individual who is participating under the Medicare program as a physician assistant for the first time may have his or her professional services covered if he or she meets the qualifications listed below and he or she is legally authorized to furnish PA services in the State where the services are performed. PAs who were issued billing provider numbers prior to January 1, 1998 may continue to furnish services under the PA benefit.
A. Qualifications for PAs
To furnish covered PA services, the PA must meet the conditions as follows:
1. Have graduated from a physician assistant educational program that is accredited by the Accreditation Review Commission on Education for the Physician Assistant (its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and the Committee on Allied Health Education and Accreditation (CAHEA); or
2. Have passed the national certification examination that is administered by the National Commission on Certification of Physician Assistants (NCCPA); and
3. Be licensed by the State to practice as a physician assistant.
B. Covered Services
Coverage is limited to the services a PA is legally authorized to perform in accordance with State law (or State regulatory mechanism provided by State law).
1. General
The services of a PA may be covered under Part B, if all of the following requirements are met:
• They are the type that are considered physician’s services if furnished by a doctor of medicine or osteopathy (MD/DO);
• They are performed by a person who meets all the PA qualifications,
• They are performed under the general supervision of an MD/DO;
• The PA is legally authorized to perform the services in the state in which they are performed; and
• They are not otherwise precluded from coverage because of one of the statutory exclusions
2. Incident To
If covered PA services are furnished, services and supplies furnished incident to the PA’s services may also be covered if they would have been covered when furnished incident to the services of an MD/DO
3. Types of PA Services That May Be Covered
State law or regulation governing a PA’s scope of practice in the State in which the services are performed applies. Carriers should consider developing lists of covered services. Also, if authorized under the scope of their State license, PAs may furnish services billed under all levels of CPT evaluation and management codes, and diagnostic tests if furnished under the general supervision of a physician.
Examples of the types of services that PAs may provide include services that traditionally have been reserved to physicians, such as physical examinations, minor surgery, setting casts for simple fractures, interpreting x-rays, and other activities that involve an independent evaluation or treatment of the patient’s condition.
4. Services Otherwise Excluded From Coverage
The PA services may not be covered if they are otherwise excluded from coverage even though a PA may be authorized by State law to perform them. For example, the Medicare law excludes from coverage routine foot care, routine physical checkups, and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Therefore, these
services are precluded from coverage even though they may be within a PA’s scope of practice under State law.
C. Physician Supervision
The PA’s physician supervisor (or a physician designated by the supervising physician or employer as provided under State law or regulations) is primarily responsible for the overall direction and management of the PA’s professional activities and for assuring that the services provided are medically appropriate for the patient. The physician supervisor (or physician designee) need not be physically present with the PA when a service is being furnished to a patient and may be contacted by telephone, if necessary, unless State law or regulations require otherwise.
