CMS Pub. 100-02, ch. 15, § 190

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.

See the Medicare Claims Processing Manual, Chapter 12, “Physician and Nonphysician

Practitioners,” §110, for payment methodology for PA services. Payment is made under

assignment only.

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, as described in §60.

3. Medical Record Documentation for Part B Services

This medical record documentation requirement applies to Part B professional services

that are paid under the Medicare physician fee schedule. Accordingly, for Part B

physician assistant covered services, the physician assistant may review and verify (sign

and date), rather than re-document notes in a patient’s medical record made by

physicians, residents, nurses, medical; physician assistant; nurse practitioner; clinical

nurse specialist; certified nurse-midwife; and certified registered nurse anesthetist

students or other members of the medical team, including as applicable, notes

documenting the physician assistant’s presence and participation in the service.

For documentation requirements specific to E/M services furnished by physicians and

certain nonphysician practitioners, see Chapter 12, section 30.6 of the Medicare Claims

Processing Manual, publication 100-04.

4. 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. A/B MACs (B) 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.

See §60.2 for coverage of services performed by PAs incident to the services of

physicians.

5. 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 physician supervision requirement under Medicare law is met under the

circumstances as follows:

Medicare Part B covers a PA’s services only if the PA performs the services in

accordance with state law and state scope of practice rules for PAs in the state in which

the PA’s professional services are furnished. Any state laws and scope of practice rules

that describe the required practice relationship between physicians and PA’s, including

explicit supervisory or collaborative practice requirements, describe a form of

supervision for purposes of the PA benefit category under section 1861(s)(2)(K)(i) of the

Act. For states with no explicit state law and scope of practice rules regarding physician

supervision of PA’s services, physician supervision is a process in which a PA has a

working relationship with one or more physicians to supervise the delivery of their health

care services. Such physician supervision is evidenced by documenting at the practice

level the PA’s scope of practice and the working relationships the PA has with the

supervising physician/s when furnishing professional services.

D. Direct Billing and Payment

Effective January 1, 2022, direct billing and payment for PA services may be made to the

PA.

E. Assignment

Assignment for PA services is mandatory.