Skilled Nursing Facilities Billing Services

Changed Role of Non-Physician Practitioners (NPPs) in Diagnostic Testing

Effective January 1, 2021, CMS permits Non-Physician Practitioners (NPPs) such as Nurse Practitioners (NPs) and Physician Assistants (PAs) to supervise diagnostic tests (including CIED management) only in states where it is allowed by state law and scope of practice. In all other states, only a physician can supervise diagnostic tests.

Previously, CMS permitted non-physician practitioners to order diagnostic tests (including CIED management) but the regulations did not address whether these practitioners could supervise others who furnished diagnostic tests.

This policy was initially implemented for the duration of the COVID-19 Public Health Emergency (PHE). In May 2021, this temporary provision was made permanent. Making this policy permanent will continue this expanded access to diagnostic testing for Medicare patients. Nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives have the green light to supervise the performance of diagnostic tests even after the COVID-19 public health emergency has ended, per the 2021 Medicare Physician Fee Schedule.

The new schedule expands the number of individuals who can order COVID tests beyond the traditional boundaries; allows patient-directed testing, permitting patients to perform sample collection at home and send the sample to a laboratory; and also permits a wider range of acceptable testing locations, including drive-through and pop-up testing sites. It also applies to tests for influenza and RSV and will make the differential diagnosis of respiratory infection more comprehensive and timelier.

Telehealth Services

While adding a number of additional services that can be provided via telehealth, CMS stated it does not have the statutory authority to authorize permanent payment for telehealth delivered in non-rural areas or for any patients located in their homes. COVID-19 PHE waivers currently allow Medicare coverage for telehealth services in urban areas and for beneficiaries in their homes. CMS will not reimburse for audio-only telephone E/M services after the PHE ends. The agency proposes to create a new virtual check-in code for longer conversations.

Office E/M Documentation

CMS also confirmed that Evaluation and Management documentation guidelines for office services will be based on either medical decision-making or time. Recording the history and exam are still necessary components for the medical record but will not be used to determine the visit level code submitted for reimbursement.

Prior to the Waiver

Previously, for certain diagnostic tests, there was a requirement for a physician to be physically onsite to meet Medicare’s supervision requirements. Under the old rules, if a physician left the office to round at the hospital, for example, and a patient came in for a visit and needed a certain diagnostic test, the test might not be able to be performed if a PA was present in the office.

The patient might be forced to return on a different day to have the test performed. With the new regulation authorizing PAs to supervise diagnostic tests, that same patient could receive the test on the same day as their office visit, avoiding an additional visit to the practice.

This rule will expand the accessibility for patients, improve efficiencies for Medicare patients, and allow practices, including those owned by nurse practitioners, long-term-care facilities, and other settings to utilize their clinical staff to a fuller extent.


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