Physician Assistants (PAs)

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

 You must:

• Be a licensed PA by the state where you practice
• Have 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
• Have 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 are reasonable and
• We consider the services physician services if a medical doctor or Doctor of Osteopathy provided 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
• Auxiliary personnel may have services and supplies provided incident to your own professional
• You may certify patient-eligibility under the Medicare home health benefit and oversee their plan of care. You may bill codes G0179, G0180, and G0181.

• You may bill us, and we pay directly for your services like we do for Nurse Practitioners (NPs) and Clinical Nurse Specialists (CNSs). For services provided before January 1, 2022, we paid your employer whether you provided services under a W-2, employer-employee employment relationship, or you were an independent contractor who got an IRS 1099 reflecting the relationship.
• You may reassign your service payment rights and incorporate as a group of only practitioners in your specialty and bill us like NPs and CNSs do. For services provided before January 1, 2022, you couldn’t reassign payment for your services, and your employer or contractor couldn’t bill reassigned services.
• Bill under your NPI. For services provided before January 1, 2022, we required:
  • That you must furnish your services under the general supervision of a physician
  • Your employer or contractor to bill under your NPI for services provided incident to your professional services.
• We apply reasonable and necessary standards to every billing request. 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, and National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). 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 your incident to services provided outside a hospital or SNF setting at 85% of the amount a physician gets under the PFS.
• We make payment to you only if no facility or other provider charges, or we didn’t pay any other service amount they provided.
• We pay your assistant-at-surgery services directly at 85% of 16% of the amount a physician gets under the PFS.
• We pay services provided incident to a PA outside a hospital and a SNF at 85% of the amount a physician gets under the PFS.
• We pay services provided incident to a PA outside a hospital at 85% 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 make the payment directly to you under the PFS

• Services, billing, and payment information: Section 190 of the Medicare Benefit Policy Manual, Chapter 15 and section 110 of the Medicare Claims Processing Manual, Chapter 12
• Qualifications: 42 CFR 410.74