Physician Extenders Non-Surgical Services

Reimbursement Policy:

Physician Extenders Non-Surgical Services

Effective Date:

August 1, 2016

Purpose:

Define the non-surgical services for which the Physician Extender(s) may be reimbursed. Rules for Assistant Surgeons apply to qualified Physician Extenders. Please refer to Horizon BCBSNJ’s Assistant at Surgery Policy.

Scope:

All products are included, except products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:

  • Physician Extender: A physician extender is a health care professional who is specially trained and certified to provide basic medical services under the supervision of a licensed physician. Physician Extenders may order tests and refer patients for specialty care based on the member's medical needs. Physician Extenders function as an agent of the physician.

Physician Extenders include, but are not limited to the following practitioners.

  • A Physician Assistant (PA) can perform physical examinations, diagnose and treat illnesses, order and interpret lab results, suture wounds and assist in surgery within the scope of their practice and license. Physician Assistants work in the same practice as a physician (PCP or specialist) and may act as an Assistant Surgeon if certified under applicable state law.
  • A Certified Nurse Midwife (CNM) is a registered nurse who has successfully completed a program of study and clinical experience in nurse-midwifery. The scope of practice of a CNM includes prenatal, postpartum and routine gynecology. CNMs work along with OBGYNs and may act as an Assistant Surgeon if certified under applicable state law.
  • A Clinical Nurse Specialist (CNS) is a registered, licensed nurse with expertise in a defined area of knowledge and practice within a selected clinical area of nursing. CNSs may act as an Assistant Surgeon if certified under applicable state law.
  • A Nurse Practitioner (NP) can obtain medical histories and perform physical exams, diagnose and treat acute health problems, chronic diseases, and order, perform or interpret diagnostic studies within the scope of their practice and license. NPs work in the same practice as a physician (PCP or specialist) and may act as an Assistant Surgeon if certified under applicable state law.
  • An Advanced Practice Registered Nurse (APRN) is a registered nurse who has met advanced educational and clinical practice requirements and who often provides services in community-based settings. The scope of service of an APRN includes primary and preventive care, mental health, birthing and anesthesia.

Policy:

Horizon BCBSNJ shall reimburse physician extenders for eligible non-surgical services when appropriately billed with modifier SA. This policy will apply to professional providers.

Procedure:

An SA modifier should be appended to all codes submitted for non-surgical services rendered by a:

  • Physician Assistant (PA)
  • Certified Nurse Midwife (CNM)
  • Clinical Nurse Specialist (CNS)
  • Nurse Practitioner (NP)
  • Advanced Practice Registered Nurse (APRN)

Reimbursement of non-surgical services appropriately appended with modifier SA will be calculated at 85% of the applicable Horizon BCBSNJ fee schedule.

Services rendered by a qualified physician extender but submitted without the appropriate SA modifier shall be subject to manual claim adjustment and recovery of any reimbursement generated.

In instances where the provider is participating, member liability shall be based on member benefits and limited to copayment, coinsurance and/or deductible, as appropriate.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

Policy 095_v1.0_03022016