# Subspecialty Billing E/M services



## RhondaJohnson (Apr 4, 2013)

Hello,

I am wondering how I should handle the following situation:

Patient is admitted to the cardiolgoy service, 
an EP consult is ordered due to sick sinus syndrome,
Patient has a pacemaker implanted by the EP doc (90 day global)
Cardiology Physician Assistant sees the patient the following day and performs a discharge.

Is the discharge by the cardiology PA billable?

Thanks - Rhonda


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## MarcusM (Apr 4, 2013)

*PA Discharge*

I would bill just like a regular discharge since the PA performed the services.  It may get denied under the global but it's good to have the record/documentation for the performed services and utilization tracking.


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## RhondaJohnson (Apr 4, 2013)

Yeah the thing is that PA's are considered their own specialty by Medicare.  So Medicare does not know that this PA is working in cardiology so the discharge will get paid.  The question is should it get paid?  Basically any PA in any surgical service can bill E/M services on patients in global periods and it will get paid because the payors have no way of knowing what specialty the PA is working in.  

And the other issue is are Cardiology and Electrophysiology considered separate specialties?  In that case it would be okay for the cardiology PA to bill.  

I'm so corn-fused!


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## MarcusM (Apr 4, 2013)

EP is a sub specialty of cardiology, ie even more specialized.


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## Cyndi113 (Apr 5, 2013)

EP is recognized as separate specialty by Medicare.


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## Pam Brooks (Apr 5, 2013)

RhondaJohnson said:


> Yeah the thing is that PA's are considered their own specialty by Medicare. Basically any PA in any surgical service can bill E/M services on patients in global periods and it will get paid because the payors have no way of knowing what specialty the PA is working in.


 
I thought the mid-levels are considered the same specialty as the practice/group in which they work.  In CPT this year, in green (new) text under New and Established patients, for this purpose anyway, *Advanced Practice nurses and physicians assistants that work with physicians are considered as working in the exact same specialty and exact same subspecialties as the physician.  *

So you're wondering if it's ok to bill the discharge by the PA who is in the same practice as the EP provider who did a 90 day global procedure, because CMS recognizes them as a different specialty?


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## EmilyDingee (Apr 5, 2013)

The discharge is global to the surgery.


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## RhondaJohnson (May 3, 2013)

We are to consider midlevels as being part of the specialty in which they practice yes.  However, CMS has no way of knowing which specialty they are practicing in.  So if a midlevel practicing in electrophysiology submits an E/M it will get paid regardless of if the patient is in a global or not.  We know they work for Electrophysiology, but CMS doesn't.

In our practice providers submit their own E/M levels, as an auditor I have to come along and decide if it really should have been billed.  Ugh!


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