Part B Insider (Multispecialty) Coding Alert

Physician Notes:

‘Scope of Practice’ Questions on the Rise, Part B MAC Says

Published on Thu Oct 13, 2022

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Tip: Check LCDs, NCDs, and medical board guidance, too.

If your practice is confused about whether a service is covered by Medicare for your provider type, you should review your supporting guidance to decrease denials, advises one Part B Medicare Administrative Contractor (MAC).

“WPS Government Health Administrators has received an increase in provider questions regarding scope of practice guidelines for various services,” the MAC says in an alert. “This includes, but is not limited to, therapy assistants, physician assistants, nurse practitioners, nurses, or medical assistants.”

Interesting: A provider’s scope of practice is determined by state licensing boards and is currently a hot topic for discussion, according to the Federation of State Medical Boards (FSMB) online guidance. “Debates on scope of practice can be contentious and are influenced by a variety of factors, including: fluctuations in the health care workforce and specific health care specialties; geographic and economic disparities in access to health care services; economic incentives for physicians (M.D., D.O.) and other health care practitioners; and consumer demand,” the FSMB says.

Reminder: When a state licenses a physician to practice medicine, that is considered legal authorization to offer care to patients — even if the license is temporary. In addition, the state determines what services the clinician can provide. “If State licensing law limits the scope of practice of a particular type of medical practitioner, only the services within the limitations are covered,” reminds Chapter 5, Section 70 of the Medicare Internet-Only Manual.

Before you send your MAC questions or submit claims, you should review both national and local coverage determinations as well as the various Medicare manuals and carrier guidance. Additionally, your MAC “may request state practice guidelines upon medical review, to support providing the service in question,” WPS says.

Check out the WPS alert, which includes links to NCDs, LCDs, and CMS manuals, at www.wpsgha.com/wps/portal/mac/site/policies/news-and-updates/scope-of-practice-provider-reminder.