# Cosign Requirements



## jhanmer83 (Jun 13, 2021)

When an RN performs the Medicare annual wellness visit, is a cosign required by the physician? We've gotten contradicting information. As of 5/20/21, Palmetto GBA said a cosign is required because it falls under the incident-to provision, however all documents from CMS say the AWV is not considered an incident-to service. We've not been able to find anything that says a cosign is required in all of the research we've done. These are being performed under direct supervision of the billing provider, but not being cosigned by the billing provider. My next question then, does "direct supervision" mean a cosign is required?


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## thomas7331 (Jun 13, 2021)

I haven't seen or heard of any formal regulations specifically requiring co-signatures - it's not one of the requirements for 'incident-to' billing, even though many practices do this as a precautionary measure.  So I'm not really sure why Palmetto would be telling you this.  Do you have a reference or link that you can share where you saw this?


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## SharonCollachi (Jun 14, 2021)

You can't bill these incident-to, with or without a cosigner.  See NGS's statement:

Providers are reminded that the IPPE and AWV are Medicare-covered services within their own benefit category. As such, they are not subject to standard “incident to” billing guidelines and must be billed by the performing provider, whether this is a physician or NPP. (click for link)


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## jhanmer83 (Jun 15, 2021)

thomas7331 said:


> I haven't seen or heard of any formal regulations specifically requiring co-signatures - it's not one of the requirements for 'incident-to' billing, even though many practices do this as a precautionary measure.  So I'm not really sure why Palmetto would be telling you this.  Do you have a reference or link that you can share where you saw this?


This is what we received from Palmetto.


Thank you for your e-mail received on May 20, 2021. You wrote to us wanting to know *if an AWV performed by a registered nurse or a medical professional have to be co-signed by the supervising physician*. The signature requirements for an AWV are no different than any other service. When the person performing the service (and eligible to perform the service) is not eligible to bill for the service, the service is billed under the supervising provider’s NPI. It is considered an incident to service. Our website outlines signature requirements for incident to services. Palmetto GBA would encourage the person rendering any part of the AWV to document and sign their documentation but *ultimately the billing provider (supervising the AWV) must authenticate all the information in the record by signing the record.*
https://www.palmettogba.com/palmetto/jmb.nsf/DID/8EEM4Q2610
We have our “chat” feature available Monday through Friday from 8:00am to 4:30pm EST to obtain assistance. You can access our chat feature from the Palmetto GBA web site at www.palmettogba.com/jmb. Once you are on our web site, you will see a little green box in the bottom right hand corner that says “chat now”. The chat representative can assist you with your Medicare questions. For further assistance, please call us at 1-855-696-0705. Medicare beneficiaries should contact 1-800-MEDICARE (1-800-633-4227) for assistance with their questions.

Sincerely,
Brenda Rack
Customer Service Advocate III
Part B E-mail Correspondence 
JM Palmetto GBA 
http://www.PalmettoGBA.com/disclaimer


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## SharonCollachi (Jun 15, 2021)

You should have asked, "Can a registered nurse perform an AWV".  Since you asked the wrong question, you got the wrong answer.  See the statement I linked and quoted above.


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## thomas7331 (Jun 15, 2021)

SharonCollachi said:


> You should have asked, "Can a registered nurse perform an AWV".  Since you asked the wrong question, you got the wrong answer.  See the statement I linked and quoted above.


This language from both NGS and Palmetto really is very confusing.  

Sharon, the link you posted above is contradictory.  At the top, it says that that AWV "must be billed by the performing provider, whether this is a physician or NPP", but then it proceeds to say that the "_AWV may be performed by a medical professional (including a health educator, registered dietitian, nutrition professional, or *other licensed practitioner), or a team of medical professionals who are directly supervised by a physician*_."  Then under question #2 it says "_The AWV...*may be performed by clinical staff under physician or NPP supervision*..._."

So it makes no sense to me to that is says that it can be performed by someone being supervised, but then can only be billed the one who 'personally' performed it.  

I believe that the source of the confusion is being they are interchanging two meanings of 'incident to' here - one refers to the coverage requirements that a service meet the definition of being 'incident to' a physician's plan of care for the treatment of an illness or injury; and the other referring to 'incident to billing' in which a mid-level provider may bill under a physician's credentials if all of the services performed meet the (first) 'incident to' definition.  The AWV is not classified as 'incident to' because it is a preventive service benefit, and isn't part of a plan of care that needs to be ordered by the physician as most other covered services have do.  

They really need to clarify this.  Either way, Palmetto's answer is clear here - services performed by the RN must be cosigned.


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## thomas7331 (Jun 15, 2021)

jhanmer83 said:


> This is what we received from Palmetto.
> 
> 
> Thank you for your e-mail received on May 20, 2021. You wrote to us wanting to know *if an AWV performed by a registered nurse or a medical professional have to be co-signed by the supervising physician*. The signature requirements for an AWV are no different than any other service. When the person performing the service (and eligible to perform the service) is not eligible to bill for the service, the service is billed under the supervising provider’s NPI. It is considered an incident to service. Our website outlines signature requirements for incident to services. Palmetto GBA would encourage the person rendering any part of the AWV to document and sign their documentation but *ultimately the billing provider (supervising the AWV) must authenticate all the information in the record by signing the record.*
> ...


I agree, it's very confusing and even contradictory.  See my response just above and let me know if that helps.  

I don't work in the Palmetto area, and this is the first time I've seen a MAC require signatures on all incident-to services - I'm kind of surprised they require this.


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## jhanmer83 (Jun 16, 2021)

thomas7331 said:


> I agree, it's very confusing and even contradictory.  See my response just above and let me know if that helps.
> 
> I don't work in the Palmetto area, and this is the first time I've seen a MAC require signatures on all incident-to services - I'm kind of surprised they require this.


Yes this is helpful. I may reach out to Palmetto and ask for clarification on incident-to as it relates to the AWV. Thanks for your help!


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## thranowski (Jun 16, 2021)

I do not think an RN is considered a "medical professional." They have to have NPIs in order to practice medicine independently, iirc. According to the Social Security Act, this is the definition of a "medical professional." I believe that state/private insurances follow these definitions, but someone can correct me if I'm wrong. I don't believe RN falls under this unless she is a "clinical nurse specialist."

(i) A physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5)).

(ii) A certified registered nurse anesthetist (as defined in section 1861(bb)(2)).

(iii) A certified nurse-midwife (as defined in section 1861(gg)(2)).

(iv) A clinical social worker (as defined in section 1861(hh)(1)).

(v) A clinical psychologist (as defined by the Secretary for purposes of section 1861(ii)).

(vi) A registered dietitian or nutrition professional.

(B) The term “clinical nurse specialist” means, for purposes of this title, an individual who—

(i) is a registered nurse and is licensed to practice nursing in the State in which the clinical nurse specialist services are performed; and

(ii) holds a master’s degree in a defined clinical area of nursing from an accredited educational institution.


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## thomas7331 (Jun 16, 2021)

thranowski said:


> I do not think an RN is considered a "medical professional." They have to have NPIs in order to practice medicine independently, iirc. According to the Social Security Act, this is the definition of a "medical professional." I believe that state/private insurances follow these definitions, but someone can correct me if I'm wrong. I don't believe RN falls under this unless she is a "clinical nurse specialist."
> 
> (i) A physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5)).
> 
> ...


I would agree with you - I would not understand 'medical professional' to include RNs.  

I think the language in the AWV descriptor that is vague in that it includes '_other licensed professional_' and '_team of such medical professionals, working under the direct supervision of a physician_'.  The references in the NPS and Palmetto publications and many outside publications allow for 'clinical staff' to fall under this, which suggests that the MACs have the understanding that it can include non-medical professional.  Even the AMA (https://edhub.ama-assn.org/steps-forward/module/2757861) states that '_most of the components of the AWV can (and should) be performed by the non-physician care team, including medical assistants (MAs)_'.  CMS really should clarify this point.


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## thranowski (Jun 16, 2021)

thomas7331 said:


> I would agree with you - I would not understand 'medical professional' to include RNs.
> 
> I think the language in the AWV descriptor that is vague in that it includes '_other licensed professional_' and '_team of such medical professionals, working under the direct supervision of a physician_'.  The references in the NPS and Palmetto publications and many outside publications allow for 'clinical staff' to fall under this, which suggests that the MACs have the understanding that it can include non-medical professional.  Even the AMA (https://edhub.ama-assn.org/steps-forward/module/2757861) states that '_most of the components of the AWV can (and should) be performed by the non-physician care team, including medical assistants (MAs)_'.  CMS really should clarify this point.


I have understood that to mean vitals, questionnaires, vaccines, growth charts/BMI, vision/hearing/etc screenings, new problems, etc. Then the provider handles the rest.


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