Physician Assistants

10.2.3.12 – Physician Assistants (Rev. 13355; Issued: 08-13-25; Effective: 05-05-25; Implementation: 05-05-25) (The physician assistant (PA) enrollment instructions in this section 10.2.3.12 supersede all other PA-specific instructions in this chapter.) A. PA Requirements Under § 410.74 Current federal regulations at 42 CFR §§ 410.74 discuss the requirements that a PA must meet. Among the requirements for coverage of PA services outlined in 42 CFR §§ 410.74(a) are that the PA (as listed in §§ 410.74(a)(2)): (i) Meets the qualifications set forth in § 410.74(c); (ii) Is legally authorized to perform the services in the state in which they are performed; (iii) Performs services that are not otherwise precluded from coverage because of a statutory exclusion; (iv) Performs the services in accordance with state law and state scope of practice rules for PAs in the state in which the PA’s professional services are furnished. Any state laws and scope of practice rules that describe the required practice relationship between physicians and PAs (including explicit supervisory or collaborative practice requirements) describe a form of supervision for purposes of section 1861(s)(2)(K)(i) of the Social Security Act. For states with no explicit state law and scope of practice rules regarding physician supervision of a PA’s services, physician supervision is a process in which a PA has a working relationship with one or more physicians to supervise the delivery of their health care services. Such physician supervision is evidenced by documenting at the practice level the PA's scope of practice and the working relationships the PA has with the supervising physician(s) when furnishing professional services; and (v) Performs the services: (A) in all settings in either rural and urban areas; or (B) as an assistant at surgery. Section 410.74(c), meanwhile, states that for Medicare Part B coverage of the individual’s services, a PA must meet all the following conditions: (1) Have graduated from a PA educational program that is accredited by the Commission on Accreditation of Allied Health Education Programs; OR (2) have passed the national certification examination that is administered by the National Commission on Certification of Physician Assistants (NCCPA); AND (2) Be licensed by the state to practice as a PA. (The PA need not be currently NCCPA- certified.) (In other words, either (1) or (2) in the first bullet must be met, and the licensure requirement in the second bullet must always be met.) B. PA Employer Prior to January 1, 2022, payment for the PA’s services could only be made to the PA’s employer, not to the PA. That is, the PA could not individually enroll in Medicare to receive direct payment for services. This also meant that the PA could not reassign benefits to the employer, for the employer must receive direct payment anyway. Pursuant to the CY 2022 Physician Fee Schedule Final Rule, however, a PA may: • Individually enroll in Medicare (e.g., as a sole proprietorship, professional corporation) • Receive direct payment for services • Establish PA groups (e.g., LLCs) • Reassign benefits to employer. The previous requirement that the PA’s employer must bill for the PA’s services has hence been eliminated. C. PA Enrollment Information With the above-mentioned change concerning PA employers (and except as stated in this subsection (C)), the contractor is advised of and/or shall adhere to the below policies, which are effective January 1, 2022. Note that reassignments of benefits are now captured via the Form CMS-855I, for the Form CMS-855R has been discontinued. 1. Newly enrolling, revalidating, and reactivating PAs shall complete the applicable Form CMS- 855I sections to the same extent as would any other individual practitioner who is able to individually enroll in and bill Medicare. 2. Transactions a. Initial Enrollment - If a PA is initially enrolling in Medicare and does not intend to reassign benefits, the PA need not complete Sections 4(F)(1) and (2) of the Form CMS-855I. (The PA may, but is not required to, furnish the primary and secondary practice location information in Section 4(F)(3).) b. Initial Enrollment - If a PA is initially enrolling in Medicare and intends to reassign benefits, the PA shall complete Sections 4(F)(1) and (2) of the Form CMS-855I. (Section 4(F)(3) is optional.) See section 10.3.1.4 of this chapter for more information on reassignments.