The first Medicare coverage of physician services provided by physician assistants was authorized by the Rural Health Clinic Services Act in 1977. In the following two decades, Congress incrementally expanded Medicare Part B payment for services provided by PAs, authorizing coverage in hospitals, nursing facilities, Rural Health Professional Shortage Areas, and for first assisting at surgery. In 1997, the Balanced Budget Act extended coverage of PA-performed medical and surgical services to all practice settings.
As of January 1, 1998, Medicare pays PAs' employers for medical services provided by PAs at 85 percent of the physician fee schedule. This rate applies to PAs practicing in all care settings including hospitals (inpatient, outpatient, and emergency departments), nursing facilities, homes, offices, and clinics; it also applies to first assisting at surgery. All visits should be billed at the full physician rate; the PA's NPI number will signal the Medicare carrier to implement the 15 percent discount. Two notable exceptions to the physician assistant 85 percent reimbursement rate, "incident to" and shared visit billing, are available for services meeting strict Medicare criteria.
The NPI is a unique 10-digit identification number for covered health care providers mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPPA). The NPI replaced the Medicare PIN, the Medicare UPIN and many private insurance company provider identifiers. The NPI is required for billing Medicare; many private payers require its usage too.
Apply for an NPI on-line at https://nppes.cms.hhs.gov/. The application is short and you should receive your number within 2 weeks. If you get new employment, change your address or change your name update, you should update your NPI at the above link. For questions about the NPI application or update process, contact Fox Systems at 1-800-465-3203 or 1-800-692-2326 (TTY).
Frequently Asked Questions about the NPI
I don't see Medicare patients; do I need an NPI number?
Yes. Not only is the NPI number used for non-reimbursement oriented electronic transfers of health care information, it will also be used by private payers.
How long will it take to get an NPI number?
After completing the NPI application, you should receive an NPI number within 2 weeks. If after 2 weeks you have not received your number contact the NPI Enumerator at: 1-800-465-3203 or 1-800-692-2326 (TTY).
May I apply for an NPI if I am not currently employed?
Yes. You may obtain an NPI even if you are unemployed, but you must notify the enumerator within 30 days of starting your job.
I'm changing jobs; do I need a new NPI?
No. Unlike the Medicare PIN and UPIN, the NPI will stay with you throughout your health care career. You should, however, notify the NPI enumerator within 30 days if any information (e.g., you employer, your address, etc.) changes.
I have multiple employers; do I need an NPI number for each one?
No. Unlike the Medicare PIN, you only need to have on NPI. Your Medicare Administrative Contractor (MAC) will know where to send payment for your services based on your employer's NPI which will also appear on the claim form.
I have an NPI number; do I still need a Medicare PIN?
No. However, you still need to enroll with Medicare by submitting a completed 855i enrollment form to your MAC.
