Advanced Practice Health Care Provider Policy, Professional (03/01/2021)

(1)

Commercial Reimbursement Policy CMS 1500 Policy Number 2021R5009A

Advanced Practice Health Care Provider Policy, Professional (03/01/2021)

IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY

You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare reimbursement policies may use Current Procedural Terminology (CPT®*), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement.

This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy.

This information is intended to serve only as a general reference resource regarding UnitedHealthcare’s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare enrollees. Other factors affecting reimbursement may supplement, modify or, in some cases, supersede this policy. These factors may include, but are not limited to: legislative mandates, the physician or other provider contracts, the enrollee’s benefit coverage documents and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare due to programming or other constraints; however, UnitedHealthcare strives to minimize these variations. UnitedHealthcare may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication.

Application

This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500), its’ electronic equivalent or its’ successor form. This policy applies to all products, all network and non-network

physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals.

Policy Overview

This policy sets forth requirements on reporting services of Advanced Practice Health Care Professionals, within a medical or other healthcare practice, to ensure submitted medical claims accurately identify the provider of service, including non-physician health care professionals.

Reporting of Services by Advanced Practice Health Care Professionals

An Advanced Practice Health Care Professional must report services rendered, within the scope of their licensure or certification, using the Advance Practice Health Care Professional’s own NPI number, unless the “Incident to” guidelines described in this policy apply.

Reimbursement Guidelines for Advance Practice Health Care Professionals

Subject to the “Incident to” guidelines in this policy, UnitedHealthcare will consider for reimbursement under this policy, medical services rendered by Advanced Practice Health Care Professionals, under the following circumstances:

(2)

Commercial Reimbursement Policy CMS 1500 Policy Number 2021R5009A • The service is a covered service under the benefit plan, and

• The service is performed by an Advanced Practice Health Care Professional, pursuant to applicable state laws and regulations.

Examples of the type of services that an Advanced Practice Health Care Professional 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.

Unless otherwise contracted with a Medical Group Non-Physician Professional fee schedule, UnitedHealthcare applies a reduction of 15% to the applicable fee schedule or allowed amount for the reimbursement of the following Advanced Practice Health Care Professionals: Physician Assistants, Nurse Practitioners, and Clinical Nurse Specialists.

“Incident-to” Services

An Advanced Practice Health Care Professional should report services rendered under their own NPI. UnitedHealthcare will not consider services rendered by an Advanced Practice Health Care Professional reimbursable under this policy as “Incident “to” a physician’s services, unless the Advanced Practice Health Care Professional is ineligible for an NPI. In accordance with CMS, in order for services to be considered “Incident to” the services of a physician or Advanced Practice Health Care Professional, the services rendered by a Nonphysician Provider must be:

• An integral, although incidental, part of the physician’s or Advanced Practice Health Care Professional’s service; • Commonly rendered without charge or included in the physician’s or Advanced Practice Health Care

Professional’s bill.

• Of a type commonly furnished in the physician’s or Advanced Practice Health Care Professional’s office or clinic; and

• Provided by the Nonphysician Provider under the physician’s or Advanced Practice Health Care Professional’s direct personal supervision. In order to meet the requirement of direct personal supervision, the supervising physician or Advanced Practice Health Care Professional and Nonphysician Provider must be associated with the same practice. Further, the physician or Advanced Practice Health Care Professional must be present in the location of service and immediately available to provide assistance and direction, throughout the time the Nonphysician Provider is performing services.

Services that meet the “Incident to” criteria above should be reported under the supervising physician’s or supervising Advanced Practice Health Care Professional’s NPI number.

“Incident to” Services for Split/Shared E/M Services

Evaluation and Management (E/M) Services in an Office or Clinic Setting:

For purposes of determining whether E/M services in an office or clinic setting should be reported by the physician or Advanced Practice Health Care Professional in a shared or split outpatient encounter, UnitedHealthcare follows CMS guidelines as follows:

• If a physician performed the E/M Service, the physician must report the E/M service under the physician’s NPI. If an Advanced Practice Health Care Professional performed the E/M service, the Advanced Practice Health Care Professional must report the E/M service under the Advanced Practice Health are Professional’s NPI. • If the physician and Advanced Practice Health Care Professional performed the E/M Service in a shared or

(3)

Commercial Reimbursement Policy CMS 1500 Policy Number 2021R5009A E/M Services in a Hospital Setting:

For purposes of determining whether E/M Services as part of a shared or split outpatient encounter in a hospital setting should be reported by a physician or Advanced Practice Health Care Professional, within the same group practice, UnitedHealthcare follows CMS guidelines as follows:

• If the physician provides any face-to-face portion of the E/M service with the patient, either the physician or the Advanced Practice Health Care Professional (not both) may report the E/M Service under their NPI number. If the physician and the patient have no face-to-face encounter, the E/M service must be reported under the Advanced Practice Health Care Professional’s NPI number. This requirement applies even when the physician participated in the service by reviewing the patient’s medical record.

Procedures with Modifier SA

Modifier SA is a payable modifier and should be reported by the supervising physician, on behalf of the nurse practitioner.

Modifier SA should be reported with covered evaluation and management (E/M) services, rendered in collaboration with a physician and billed under the supervising physician’s NPI number, presuming the physician provided direct on-site supervision/direction.

Covered services, billed with Modifier SA, will be considered for reimbursement under this policy and Modifier SA will be used for documentation purposes.

Definitions

Advanced Practice Health Care Professional

A healthcare practitioner other than a physician, licensed by a state to assist or act in the place of a physician who may bill directly under applicable state law. An Advanced Practice Health Care Professional includes, without limitation, certified nurse midwives, physician assistants, nurse practitioners, and clinical nurse specialists.

Collaboration A physician works with an Advanced Practice Health Care Provider to deliver health care services with medical direction and appropriate supervision, as required by the law of the state in which the services are furnished. In the absence of state law governing collaboration, collaboration is to be evidenced by the Advanced Practice Health Care Provider’s documentation of their scope of practice and indicating the relationship they have with the physician to deal with issues outside their scope of practice. The collaborating

physician does not need to be present when the services are furnished and does not need to make an independent evaluation of each patient who is seen by the Advanced Practice Health Care Provider.

Modifier SA Nurse practitioner rendering service in Collaboration with a physician. Nonphysician Provider Auxiliary personnel, such as nurses and medical assistants, acting under the

supervision of a physician or Advanced Practice Health Care Professional, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician.

(4)

Commercial Reimbursement Policy CMS 1500 Policy Number 2021R5009A

Questions and Answers

1

Q: What happens when a patient sees an Advanced Practice Health Care Provider and a physician at the same encounter?

A: In the office/clinic setting, when an E/M service is a shared/split encounter between a physician and an Advanced Practice Health Care Professional, the service is considered to have been performed “Incident to” if the Requirements for “Incident to” described in this policy are met and the patient is an established patient. If “Incident to” requirements are not met for a shared/split E/M service, the service should be reported under the Advanced Practice Health Care Professional’s NPI number. Please see the section above entitled ”Incident to” Services for Split/Shared E/M Services for more information.

2

Q: Does the physician actually have to see the patient or actively participate in each service in order for “Incident to” services to apply?

A: No, services provided by Nonphysician Providers, who are associated with the same practice as the physician, may be covered as “Incident to” the physician’s service if the physician provides direct on-site

supervision/direction, when the service is provided, even when the patient does not see the physician.

Resources

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services Health care Common Procedure Coding System (HCPCS)

Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services History

3/1/2021 Policy Version Change

Verbiage Changes: Overview, “Incident to” Services and Procedures with Modifier SA Sections

Title and Verbiage Changes: Reimbursement Guidelines for Advanced Practice Health Care Providers and “Incident to” Services for Split/Shared E/M Services Sections

New Policy Sections Added: Reporting of Services by Advanced Practice Health Care Professionals

Definitions Verbiage Changes; Modifier SA

New Definitions Added:Advanced Practice Health Care Professional and Nonphysician Provider

Questions and Answers Section 1 & 2 updated History Section: Entries prior to 1/1/2019 archived 4/13/2020 Added the word “Commercial” to the policy header.

(No New Version) 9/16/2019 Policy Version Change

Verbiage Change: Overview and Reimbursement Guidelines Sections Questions and Answers and Definitions Sections updated

6/24/2019 Policy Version Change Policy Title Change

Policy Verbiage Change: Overview Section, Reimbursement Guidelines Section, Incident to” Services Section, Split/ Shared E/M Services Section, Procedures with SA Modifier Section, Questions and Answers Section updated

(5)

Commercial Reimbursement Policy CMS 1500 Policy Number 2021R5009A 9/1/2017 _{Policy implemented by UnitedHealthcare Employer & Individual}

5/10/2017 _{Policy approved by the Reimbursement Policy Oversight Committee}