Are services provided as incident to a NPP subject to guidelines?
Services can be provided as incident to a NPP only when that NPP is enrolled with the Medicare program Services and supplies having their own benefit category are not subject to incident to guidelines
What is the Opps and when was it implemented?
The OPPS was implemented in 2000 and significantly changes how hospitals are reimbursed for outpatient services under Medicare. Access the below OPPS related information from this page.
What can an NPP bill under the MPFS?
NPPs can bill for counseling or coordination of care in their own names at 85 percent of the MPFS. Also, while qualified NPPs may perform diagnostic tests and be supervised by physicians while doing so, diagnostic tests may never be billed incident-to.
What are the Opps payment rates and copayment amounts?
New OPPS payment rates and copayment amounts will be effective January 1, 2021. All copayment amounts will be limited to a maximum of 40 percent of the APC payment rate. Copayment amounts for each service can’t exceed the CY 2021 inpatient deductible of $1,484. For most OPPS services, copayments are set at 20 percent of the APC payment rate.
Objective
To set forth the requirements for NPP billing for their services under the three models of reimbursement.
Policy
Professional services rendered by certain licensed non physician providers or NPPs may be billed directly to the Medicare program, provided that the services are within the NPP’s scope of practice, as defined by State law.
Incident to Billing by Non-Physician Providers (NPPs)
Under certain circumstances, services furnished by NPPs may be billed under a physician’s provider number as “incident to” the physician’s services. To be covered as “incident to” the services of a physician, the services must be:
Other Non-physician Providers
For practice information on other providers such as Certified Registered Nurse Anesthetists and Anesthesiologist Assistants, Nurse Specialists, please see this MLN Booklet (link is external and opens in a new window) detailing NPP coverage from CMS.
What is CMS A2?
A2. CMS defined “initial comprehensive visit” in the November 13, 2003, S&C-04-08 and stated that NPPs may perform any medically necessary visits even if they occur prior to the initial comprehensive visits in both SNFs and NFs. Medically necessary visits that NPPs perform on or after November 13, 2003, may be billed to the carrier when collaboration and billing requirements are met in the SNF and NF setting. The Survey & Certification letter S&C-04-08, may be found at
What is Medicare A15?
A15. If the resident’s stay is being paid for by a source other than Medicare or Medicaid AND the resident is residing in a Medicare/Medicaid dually-certified facility, follow the most stringent requirement. If the resident is residing in a Medica re only or a Medicaid only certified facility, then providers should follow the requirements for that specific certified facility.
Does CMS pay for face to face visits?
A3. No. CMS only pays for medically necessary face-to-face visits by the physician or NPP with the resident. Since the NPP is performing the medically necessary visit, the NPP would bill for the visit.
Can NPPs sign initial orders for SNF?
A8. NPPs may not sign initial orders for an SNF resident. However, they may write initial orders for a resident (only) when they review those orders with the attending physician in person or via telephone conversation and have the orders signed by the physician.
What are the new codes for CPT?
The AMA CPT Editorial Panel established 13 new PLA codes, specifically, CPT codes 0227U through 0239U, effective January 1, 2021. Also, the AMA CPT Editorial Panel established two new PLA codes, specifically, CPT codes 0240U and 0241U effective October 6, 2020. Because CPT codes 0240U and 0241U were released on October 6, 2020, they were too late to include in the October 2020 OPPS update and are instead being included in the January 2021 update with an effective date of October 6, 2020. Table 2 of CR 12120 lists the long descriptors and status indicators for the codes.
When will the HCPCS start?
There are two existing HCPCS codes for certain drugs, biologicals, and radiopharmaceuticals in the outpatient setting that will start to receive pass-through status beginning on January 1, 2021. These HCPCS codes are listed in Table 16 of CR 12120.
What is the status indicator for P9099?
Effective January 1, 2021, the status indicator for HCPCS code P9099 has changed from SI = “E2” (Items, codes and services for which pricing information and claims data aren’t available. Not paid by Medicare when submitted on outpatient claims (any outpatient bill type)) to SI = “R” (Blood and blood products that are paid under OPPS; separate APC payment) as described in
What is the APC offset?
This deduction is known as the device offset, or the portion(s) of the APC amount that is associated with the cost of the pass-through device. The device offset from payment represents a deduction from pass-through payments for the applicable pass-through device.
What are the new CPT codes for Moderna?
On November 10, 2020, the AMA released six new CPT codes associated with the Pfizer and Moderna COVID-19 vaccines. Two of the six CPT codes (91300 and 91301) refer to the specific vaccine products, while the other four CPT codes (0001A, 0002A, 0011A and 0012A) describe the service to administer the vaccines. These codes will be available for use once the applicable coronavirus vaccine product receives EUA or approval from the FDA. The codes have been included in the January 2021 I/OCE. In addition, on December 17, 2020, the AMA released three new CPT codes associated with the AstraZeneca and University of Oxford COVID-19 vaccine. The codes, specifically, CPT codes 91302, 0021A, and 0022A, will be available for use once the vaccine receives EUA or approval from the FDA.
When will G2067-G2080 be paid?
For CY 2021, we are allowing these OTP codes to be billed on institutional claims only by certified OTP providers who are enrolled with Medicare as an OTP. Therefore, we’re changing status indicators for G2068-G2080 from SI “E1” (Not paid by Medicare when submitted on outpatient claims (any outpatient bill type)) to SI “A” (Not paid under OPPS. Paid by MACs under a fee schedule or payment system other than OPPS) so the payment can be made on the OTP fee schedule effective January 1, 2020.
Is there an exception to the OPPS C-APC policy?
In the interim final with request for comments (IFC) entitled, ‘‘Additional Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency”, published on November 6, 2020, we stated that effective for services furnished on or after the effective date of the IFC and until the end of the PHE for COVID-19, there’s an exception to the OPPS C-APC policy to ensure separate payment for new COVID–19 treatments that meet certain criteria (85 FR 71158 through 71160). Under this exception, any new COVID-19 treatment that meets the two following criteria will, for the remainder of the PHE for COVID-19, will always be separately paid and won’t be packaged into a C-APC when it’s provided on the same claim as the primary C-APC service.