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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 () or MLN Matters article SE0418 ().