Modifier SA Reporting Guidelines for both Medicaid and DSNP

Modifier SA is an HCPCS Level II modifier defined as "Nurse practitioner rendering service in collaboration with a physician" on professional claims when Advanced Practice Providers (APPs) deliver services billed "incident to" a supervising physician. This modifier signals that an APP, such as a Certified Nurse Practitioner (CRNP) or Physician Assistant (PA) provides the service, when the claim uses the supervising physician's NPI.

Modifier SA is required on each CPT/HCPCS line item when:

• An APP provides the service.
• The service is billed "incident to" a physician, meaning the supervising physician’s NPI is in both the billing and rendering provider fields.
• All "incident to" billing requirements are met, including an established physician plan of care, active physician supervision, and compliance with the APP's state scope of practice.

This applies to services by various APPs, including PAs and CRNPs.

Key "incident to" requirements for Modifier SA reporting include:

• An active, physician-established plan of care for the encounter.
• Physician approval and sign-off on new problems or care plans before APP "incident to" billing.
•  The APP practicing within their state-defined scope.
•  Active involvement of supervising physician during treatment.

If these criteria are not met, the APP must bill under their own NPI without Modifier SA, or the claim may face denial. Please note, Highmark Wholecare does credential and contract directly with PAs and CRNPs and will reimburse them directly. The SA modifier is not required in this billing scenario.

For claim submission and when billing under the supervising physician, the supervising physician’s NPI must be in both the billing and rendering provider fields, and Modifier SA must be appended to each service line provided by the APP in an "incident to" context. Failure to adhere to these billing mechanics can lead to claim rejection.