Know your codes when billing for PAs
Know your codes when billing for PAs
Based on information from the American Academy of Physician Assistants (AAPA), Alexandria, VA, the following billing guidelines apply for PAs:
1. Medicare coverage usually is limited to 85% of fees a physician would charge. As of Jan. 1, 1998, Medicare pays the PAs' employers for medical services provided by PAs in all settings at 85% of the physician's fee schedule, says Nancy Hughes, AAPA's director of communications. Assignment is mandatory, and state law determines supervision and scope of practice. (The chart on p. 133 provides more specific information). Hospitals that bill Part B for services provided by PAs may not at the same time include PAs in the DRG calculations by including PA salaries in the hospital's cost reports.
Outpatient services provided in offices and clinics still may be billed under Medicare's "incident to" provisions if Medicare's billing guidelines are met. This allows payment at 100% of the fee schedule if: (1) the physician is physically on site when the PA provides care; (2) the physician treats all new Medicare patients (PAs may provide the subsequent care); (3) established Medicare patients with new medical problems are personally treated by the physician (PAs may provide the subsequent care).
Generally, for a procedure to be considered an "incident to" service, the following criteria must be met:
· The service must be medically necessary.
· The service performed must be one that is typically performed in a physician's office.
· The service performed should be within the scope of practice of the PA.
· The physician should be in the building (on-site) when the service is rendered.
· The physician must personally see the patient on the patient's first visit to the practice.
Here's an example: A 76-year-old Medicare beneficiary comes into a physician's office with a laceration. The physician is attending to another patient within the suite of offices. The PA cleans, sutures, and bandages the laceration, and the Medicare beneficiary leaves the office without seeing or having any direct contact with the physician.
"Our interpretation of the language in the final rules would make this a covered 'incident to' procedure, which would be reimbursed at 100% of the physician's fee schedule," says Hughes.
Medicare requires that the claim form on an "incident to" service be filled out using the physician's name and provider number (as if the physician had performed the service). Check with your local carrier for more details regarding procedures for billing "incident to" services.
According to the Balanced Budget Act of 1997, PAs using the 85% reimbursement rule may be either W-2 employees or independent contractors. The employer still would bill Medicare for the services provided by the PA. Under the "incident to" provision, PAs may be leased W-2 employees, but not independent contractors. All PAs who treat Medicare patients must have a provider identification number for use on the HCFA 1500 claim form.
2. Medicaid reimbursement for PA services is equal to or slightly lower than that for physicians. Presently, 45 states cover medical services provided by PAs under their Medicaid programs. The rate of reimbursement, which is paid to the employing practice and not directly to the PA, is either same as or slightly lower than that paid to physicians.
3. Private insurers generally cover medical services provided by PAs. An American Medical Association (AMA) policy in place since April 1978 recommends that ". . . reimbursement for services of a physician assistant be made directly to the employing physician. In instances where the PA is providing services in the physicianoffice and in conjunction with the physician, the cost of such services would appropriately be a part of the physician's charge, as is now the case with other personnel [he] employs. When the PA provides physician-like services to a patient under the direction of, but in a location physically remote from, the employing physician, AMA has recommended that the physician bill for such services on the basis of the usual, customary and reasonable charges concept."
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