Clinical Social Workers
Reimbursements for all clinical social worker (CSW - specialty 80) services reimbursement amounts remain, as set by law, at 75 percent of the clinical psychologist reimbursement level.
Facility Setting Payment Differential
As part of the resource-based practice expense initiative, the Centers for Medicare & Medicaid Services (CMS) has replaced the previous policy that systematically reduced the practice expense relative value units (RVUs) by 50 percent for certain procedures performed in facilities with a policy that would generally identify two different levels (facility and non-facility) of practice expense RVUs for each procedure code depending on the location of the service.
Some services, by the nature of their codes, are performed only in certain settings and will have only one level of practice expense RVU per code. Many of these are evaluation and management codes with code descriptions specific as to the location of the service. Other services, such as most major surgical services with a 90-day global period, are performed entirely or almost entirely in the hospital, and those services generally are provided with a practice expense RVU only for the out-of-office or facility setting.
The higher non-facility practice expense RVUs are generally used to calculate payments for services performed in a physician’s office and for services furnished to a patient in the patient’s home, facility, or institution other than a hospital, skilled nursing facility (SNF), or ambulatory surgical center (ASC). For these services, the physician typically bears the cost of resources, such as labor, medical supplies and medical equipment associated with the physician’s service.
The lower facility practice expense RVUs generally are used to calculate payments for physicians’ services furnished to hospital, SNF and ASC patients. The cost for non-physicians’ services and other items, including medical equipment and supplies, are typically borne by the hospital, SNF or ASC.
The facility-based fees are linked to their own separate RVUs independent of the non-facility fee RVUs. This differs from the former site-of-service fee reductions, which were based simply on a percentage reduction of the full fee rather than a separate RVU.
2013 Non-physician Practitioner Fee Schedule
Sections 4511 and 4512 of the Balanced Budget Act of 1997 (BBA) provide that payment for the professional services of these non-physician practitioners will be linked to the physician fee schedule.
Payment may be made for services furnished by nurse practitioners (NPs), physician assistants (PAs) and clinical nurse specialists (CNs) in all settings permitted by state law, but only if no facility or other provider charges are paid in connection with the service. Payment would be equal to 80 percent of the lesser of the actual charge or 85 percent of the physician fee schedule. Payment for a PA’s services may only be made to the PA’s employer. Under certain circumstances, a PA as an independent contractor qualifies as an employment relationship where payment is made to the employer.
Practitioners Subject to Mandatory Assignment
Some practitioners who provide services under the Medicare program are required to accept assignment for all Medicare claims for their services. This means that they must accept the Medicare allowed charge amount as payment in full for their practitioner services. The beneficiary’s liability is limited to any applicable deductible plus the 20 percent coinsurance. The following practitioners must accept assignment for all Medicare covered services they furnish, and carriers do not send a participation enrollment package to these practitioners. The non-participating fee schedule amounts and limiting charges do not apply to services rendered by:
- Specialty 32 - Anesthesiologist assistants (AAs)
- Specialty 42 - Certified nurse midwives
- Specialty 43 - Certified registered nurse anesthetists (CRNAs)
- Specialty 50 - NPs
- Specialty 68 - Clinical psychologists
- Specialty 71 - Registered dietitians/nutritionists
- Specialty 73 - Mass Immunization Roster Billers
- Specialty 80 - Clinical social workers
- Specialty 89 - CNs
- Specialty 97 - Physician assistants
Note: The provider type Mass Immunization Biller (specialty 73) can bill only for influenza and pneumococcal vaccinations and administrations. These services are not subject to the deductible or the 20 percent coinsurance.