TABLE 3-2 Medicare Claims Payment Structure by Provider Type

Provider

Office Services

Hospital Services

Incident to a Physician’s Servicesa

Surgery Services

Medicare Provider ID

Direct Reimbursement

Physician

100% of physician fee

100% of physician fee

N/A

Usually receives a global fee

Own provider ID required

Physician or employer may be reimbursed directly

Nurse practitioner (NP)

85% of physician fee, 100% if billed “incident to”a in a physician’s office or clinic using MD’s provider ID

Usually salaried; nursing costs are part of hospital payment

100% of physician fee (must bill under the MD’s provider ID)

Usually accounted for in surgeon’s global fee

Own ID possible, but not required

NP or employer may be reimbursed directly

Certified nurse midwife (CNM)

65% of physician feeb

 

100% if billed “incident to” in a physician office or clinic using MD’s provider ID

Usually accounted for in surgeon’s global fee

Own ID possible, but not required

CNM or employer may be reimbursed directly

Physician assistant (PA)

Lesser of the actual charge or 85% of physician fee

Lesser of the actual charge or 75% of physician fee

100% if billed “incident to” in a physician office or clinic using MD’s provider ID

Use assistant surgeon modifier

Own ID required

Only employer can be reimbursed directly

a“Incident to” is used by Medicare to denote cases in which work is performed under the direction and supervision of a physician. Criteria for “incident to” billing require that the physician be on site (in the suite of offices) at the time the service is performed, that the physician treat the patient on the patient’s first visit to the office, and that the service be within the NP scope of practice in the state.

bCNM payment will increase to 100 percent of physician fee as of January 1, 2011.

SOURCE: Chapman et al., 2010. Copyright © 2010 by the authors. Reprinted by permission of SAGE Publications.



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