EM Coding Alert

Question: I am receiving denial C0-170 (Payment is denied when preformed/billed by this type of provider) from Medicare when I bill for an initial nursing facility visit our physician assistant (PA) did. I am using place of service code 31 (Skilled Nursing Facility) and provider type 38 (Physician assistant). Why am I getting this denial?

Alabama Subscriber

Answer: You cannot bill an initial visit in a skilled nursing facility (SNF) or nursing facility (NF) using 99304-99306 (Initial nursing facility care, per day, for the evaluation and management of a patient ...) under a physician assistant (PA), per Medicare rules. Medicare says that a physician must perform this type of service, per 42 Code of Federal Regulations (42 C.F.R. 483.40 [c] [4]).

According to CMS, the Social Security Act states in Section 1819(b)(6)(A) that “the medical care of every resident must be provided under the supervision of a physician.” This means non-physician practitioners, including PAs, cannot perform the initial comprehensive visit in SNFs.

Remember: CMS defines the initial visit is defined as “the initial comprehensive assessment visit during which a physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the nursing facility resident.”

Additionally, per the Long Term Care regulations (42 CFR 483.40 [c][4] and [e][2]), the physician may not delegate a task that the physician must personally perform. Therefore, the physician may not delegate the initial visit in a SNF to your PA.

Keep in mind: This rule also applies to the NF (POS 32) with one exception: A qualified NPP, who is not employed by the facility, may perform the initial visit in the NF setting when the state law permits.

Learn more: You can read more about Medicare’s billing regulations for NPPs in the SNF and NF setting by reading the Medicare Claims Process Manual, Chapter 12, Section 30.6.13 (www.cms.gov/manuals/downloads/clm104c12.pdf) or MLN Matters article SE0418 (www.cms.gov/MLNMattersArticles/downloads/SE0418.pdf).