With the new PECOS requirement, hospitals have been scurrying to get employed PAs enrolled to meet the “ordering/referring” rule.
Some MSPs who are responsible for physician credentialing and enrollment in Medicare have been asked to present Medicare contractors with current certification information. In some states, maintenance of certification is not a requirement for licensure; nor is it a requirement for Medicare enrollment. The PA must have passed the certifying exam. There is no mention of maintenance of certification. Transcripts from the PA program are not required if proof can be presented that the PA is NCCPA certified. In this case, certification and license are all that is required.
The relevant Medicare regulations are below:
Medicare Benefit Policy Manual
Chapter 15 – Covered Medical and Other Health Services
Table of Contents
(Rev. 117, 12-18-09) http://www.cms.gov/manuals/Downloads/bp102c15.pdf
190 - Physician Assistant (PA) Services
(Rev. 1, 10-01-03)
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
The AAPA contacted CMS to seek clarification on this issue. The following response was received on January 19, 2011:
“The regulations at 42 CFR 410.74 that contain the PA qualifications should be
interpreted as follows:
1. Have graduated from a PA educational program that is accredited by the Commission on Accreditation of Allied Health Education Programs and be licensed by the State to practice as a PA; or
2. Have passed the national certification examination that is administered by the National Commission on Certification of PAs and, be licensed by the State to practice as a PA.”
For more information, or questions regarding the credentialing and enrollment of PAs, please contact:
Tricia Marriott, PA-C, MPAS
Director, Reimbursement Policy
American Academy of Physician Assistants