# PA Assist Documentation Requirements



## ercoder65 (Jan 8, 2010)

I code for an Orthopedic group. They usually use PA's to assist. My question is this: what are the documentation requirements for coding and billing of PA assist surgeries? All my surgeons do is in the heading of the report, below the diagnosis and procedural statement, is "Assistant= So and So, PA-C". Is this considered compliant in so far as sending out a claim form for the PA? Or does the PA need to document what he assisted the surgeon on? I feel uncomfortable sending out claims for the assist without any documentation, but my supervisor is adamant that I do so. Thanks in advance!!


Rich


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## Lisa Bledsoe (Jan 8, 2010)

The PA does not need to document his/her own note, but the surgeons note must state what assistance the PA provided; what he/she did to assist.  This would be necessary even if the assistant was another MD.  The only time you need two separate notes is when it a s a co-surgeon surgical procedure.


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## nyyankees (Jan 8, 2010)

ercoder65 said:


> I code for an Orthopedic group. They usually use PA's to assist. My question is this: what are the documentation requirements for coding and billing of PA assist surgeries? All my surgeons do is in the heading of the report, below the diagnosis and procedural statement, is "Assistant= So and So, PA-C". Is this considered compliant in so far as sending out a claim form for the PA? Or does the PA need to document what he assisted the surgeon on? I feel uncomfortable sending out claims for the assist without any documentation, but my supervisor is adamant that I do so. Thanks in advance!!
> 
> 
> Rich



You will have to make sure that the surgical code is assitant-surgery acceptable (you can find on Medicare website). PA's get AS modifiers not 80. Hope this helps. There was a great article on this subject in the Coding  Edge magazine a few months ago (Oct??).


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## ercoder65 (Jan 8, 2010)

Thanks Lisa! So basically what they are making me do is really non-compliant?


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## Lisa Bledsoe (Jan 8, 2010)

Here is part of a memo I sent my surgeons: 

However, for every operative note it must be clearly documented as to the reason the assistant was required and what role the assistant played.  It is not sufficient to simply state that the assistant was a medical necessity for the entirety of the surgical case.  The assistant's role must also be documented in the body of the operative report.  Use of the term “we” and stating that the assistant performed a certain technique and/or specific assistance with a technique will be helpful in obtaining reimbursement for assistant services.  
Also, you must use modifier AS for non-physician assistants (PA's, NPP's).  Modifier -80 is for physicians as assistants only.

I wouldn't necessarily say you are being asked to do something that is non-compliant, the doctors need to be educated on the requirements for their op note documentation.


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## RebeccaWoodward* (Jan 8, 2010)

Lisa Curtis said:


> Here is part of a memo I sent my surgeons:
> 
> However, for every operative note it must be clearly documented as to the reason the assistant was required and what role the assistant played.  It is not sufficient to simply state that the assistant was a medical necessity for the entirety of the surgical case.  The assistant’s role must also be documented in the body of the operative report.  Use of the term “we” and stating that the assistant performed a certain technique and/or specific assistance with a technique will be helpful in obtaining reimbursement for assistant services.
> Also, you must use modifier AS for non-physician assistants (PA’s, NPP’s).  Modifier -80 is for physicians as assistants only.
> ...




I think Lisa has provided a great example. Some carriers are vague or provide little guidance on what is expected for assistant documentation.  Like Lisa, we have a policy, across the board and expect some type of documentation regarding the role of each assistant.  For those procedures that have an assistant payment indicator of zero (0-assistant surgery may be paid w/ supporting documentation), it is critical that the documentation can stand on its own. Appeals are far easier with good documentation...


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## ercoder65 (Jan 8, 2010)

Okay, but the issue is my supervisor is not a coder and knows nothing about coding; worse is she won't listen to any professional advice nor take steps to correct this since she is (understandably) intimidated by physicians. If this is not necessarily non-compliant, then would you as a professional coder maintain status quo even though you know that its not the correct way to document PA assists? I am not sure of what my options are at this point.


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## LLovett (Jan 8, 2010)

I fight this fight everyday. Even if your boss is a non-coder I would think she would understand the concept of "if its not documented it didn't happen". We can only code based on what we can prove happened based on the documentation. The header of an op report is not what we code from, we code based on the body. If you can't tell there was more than one person doing the work based on the body of the op report how can you bill for more than one person? Maybe approaching it from that standpoint will make more sense to her. The administrators I work with are non-coders but they fully understand the concept of documentation supporting what is billed.

If you can't convince them maybe its time to bring in an outside opinion, get an external consultant to do an audit and outline your areas of risk. It sucks to have to do this but sometimes thats what it takes to get them to listen to you.

Good luck,

Laura, CPC, CEMC


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## RebeccaWoodward* (Jan 8, 2010)

In addition to what Laura stated...

Once your practice is on the carriers "radar" for lack of assistant surgery documenation (as an example), you can believe that they will begin to deny these services routinely.  Grant it...assistant PA surgery isn't a huge money maker but over a period of time, the adjustments are bound to catch someone's eye. I imagine she'll be explaining 2 things to the providers/upper mgmt when/if this happens...1) why the adjustments/denials have increased 2) why it wasn't brought to the physicians attention sooner...


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## ercoder65 (Jan 8, 2010)

Since this facility seems to care most about the bottom line, I doubt my supervisor will give the go ahead for an outside audit (due to paying $$$). What is my next plan of attack?


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## LLovett (Jan 11, 2010)

Many auditing companies will do a sample audit for free (usually up to 10 cases). That might be enough to convince them there is a problem and either go forward with a bigger audit or change their ways.

Try The Coding Network http://www.codingnetwork.com/

I really like Mark and the coders are great.

Good luck,

Laura, CPC, CPMA, CEMC


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## ercoder65 (Jan 11, 2010)

Thanks Laura!


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## ercoder65 (Jan 13, 2010)

*Shot down again!*

Well, bad news. Had a coding meeting yesterday afternoon with my supervisor. I explained how the surgeons need to document why they needed a PA assist, and what the PA did while assisting. My supervisor then got upset and stated I was incorrect, that her 'contact' said all the surgeon has to do is state a PA was with him; I disagreed and it became a somewhat heated conversation. Anyway, at 9 this morning I have to go see HR, so I am expecting to be let go. This is a great example of a department being run by someone who is very ignorant of the importance of documentation. She says that the way she does it, all the claims get paid, and I replied just because they are paid doesn't mean your guidelines are compliant. SO, we'll see. I'll keep everyone posted. I appreciate all the information I received. I just wish I knew who I can go to listen to me? We don't even have a compliance officer at this place!


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## RebeccaWoodward* (Jan 13, 2010)

OMG!  That is horrible!  I'm rooting for you...

Sincerely,


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## LLovett (Jan 13, 2010)

*That is called retaliation and it is illegal*

I would make sure they know that. Unfortunately you are already in that meeting as I am reading/responding.

You can not kill the messenger no matter who you are. If they do anything to you, fire, threaten, intimidate, demote, etc.. you need to file suit against them. I'm not sure where you are but there are attorneys all over that deal with this. Generally the same ones that do the qui tam suits will handle this because they tend to go hand in hand. Do not take this, fight back!

I know some attorneys in Ohio if that would help you in anyway. You could talk to them if nothing else and get a better idea where you stand.

Laura, CPC, CPMA, CEMC


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## ercoder65 (Jan 13, 2010)

*Thanks for the support*

Laura and Rebecca,

Thank you so much for your support. It does mean a great deal to me. Sometimes I feel there is nobody out there protecting me, and all we do, as coders, is try and follow guidelines and be compliant. I will reply to this thread after my interview, to let you gals know of the results. Thanks again!!  


Richard


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## ercoder65 (Jan 13, 2010)

I'm just getting my ducks in a row, and while I know that nobody can give me a numerical percentage of risk that this Orthopedic Facility was taking by not documenting the PA assist part, can anyone give me a subjective idea of this risk via low, medium or high scale? I am trying to put facts together. Thanks!


Rich


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## LLovett (Jan 13, 2010)

Well if you are billing out services that are not supported by documentation you are at a high level of risk because you are basically commiting fraud. It would be no different than if they billed based on the header of the note which said "CABGx 3 and wedge resection lung" but there was no documentation of the wedge resection in the body of the op report. 

Having said that I thought I would post a link to another thread I started about this since there is some ortho references in it. I no longer have ortho, CVT is my big headache which explains my example!

https://www.aapc.com/memberarea/forums/showthread.php?t=25364&highlight=assist+surgery

Also here is a link to a study by the OIG stresses the importance of increased controls over payments for services by NPP.

http://oig.hhs.gov/oei/reports/oei-02-00-00290.pdf

I am more than happy to back you and will help in any way I can.

Laura, CPC, CPMA, CEMC


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## ercoder65 (Jan 14, 2010)

*Scared stiff!*

Okay,

Here is what went down. Was called into the HR office at 9. They asked if everything was okay, and they said they'd hate to lose me. So, I asked if I can be candid and they said go ahead.............I did. I let them know how helpless we felt in the coding department because our supervisor wouldn't listen to our advice. I explained about documentation. I was surprised when the HR manager said she absolutely agreed with me; she did some coding way back when. Anyway, I felt it was a productive meeting. She asked if I planned on leaving and I said I am actively looking for a new job. She said not to go anywhere, and to give her 1 week to try and get something resolved.

I then went back to my desk feeling somewhat better, but we'll see. HR then called in my co-worker friend to speak with her. Apparently she told themthe exact same thing I said, and said she didn't want me to leave. A few hours later, my supervisor and the HR department are in a long meeting. Now I didn't see this, but other co-workers said that after the meeting my supervisor looked very pissed off. SHe then went back to her office and closed the door(which she never does) for the rest of the day. What worries me, however, is another co-worker said she sa that the supervisor had her cronies(the ones that crawl up a boss' butt)in her office for a long time, and they all looked mad. I am wondering if now I have a bullseye on my back. STill trying to gather info on what I can do to protect myself; at least it sounds like HR may be on my side for having a valid point.

I'll keep everyone posted on how this day goes!

Rich


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## RebeccaWoodward* (Jan 14, 2010)

You're doing the right thing, Rich.  Reminds me of a time when a former manager stated..."*If it's paid, it's billable*" .  Needless to say I fought this tooth and nail because the code in question was absolutley, 100% not billable in the manner she wanted it billed.  Long story short...we receive a kind letter from the carrier requesting a refund...I had the honor of presenting the letter to her...


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## ercoder65 (Jan 14, 2010)

LOL! Thats funny Rebecca, yet it's not; I've always wondered how people get in positions of management when they are ignorant of what the people under them do, and what ethics they abide by?


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## FTessaBartels (Jan 14, 2010)

*Bravo*

Rich,
Bravo to you for doing the right thing and bringing the issue up. Integrity and reputation are invaluable; once lost they can virtually never be regained. 

Conduct yourself in a highly professional manner at all times. If your supervisor behaves less than professionally, speak to her about it directly, in person and in private.  And, of course, make a record of it. 

If your supervisor's future actions are retaliatory, then go to HR with those concerns. 

Your employer is lucky to have you!

F Tessa Bartels, CPC, CEMC


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## ercoder65 (Jan 14, 2010)

Thanks Tessa!!


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## Mjones7 (Jan 15, 2010)

ercoder65 said:


> Since this facility seems to care most about the bottom line, I doubt my supervisor will give the go ahead for an outside audit (due to paying $$$). What is my next plan of attack?



ercoder65

Sometimes we just got to pick our battles  In this situation, I think you should simply provide the information verbally as will in writing you should find some resources to share with your supervisor.  I believe as coders we have a responsibility to interpet and educate to maintain compliance and sometimes as you know we have to agree to disagree.  This matter although a concern, I would not view it as a need to plan an attack (lol).  Make the recommendation respectfully and move on.  Best Wishes!


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## ercoder65 (Jan 19, 2010)

*frustrated*

Okay,

We had a coding meeting and again, I stressed the importance of documenting what the PA did to assist the surgeon. After an hour and a half of showing her examples, she said she would implement this policy, but it would take time and we were to continue on as usual(which I didn't like to hear). Now I am told, by a friend who happens to be inside the 'circle', that my supervisor is doing everything she can to disprove me and hasn't brought this up to her boss, nor the doctors. I am also told she is documenting my passion for doing things right, as being confrontational with her. Is there an organization, or a person, I can talk to that would back me up? I feel so overwhelmed. I really believe in doing things the right way; what is so hard to make the physicians document the help the PA's perform? Also, if you explain this to the PA's, I am sure they'd make the doctors document rather then to not bill or worse, to risk an audit and open up a can of worms!! I am soooooo frustrated. I am sending my resume out becuase I can see the writing on the wall.


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## RebeccaWoodward* (Jan 19, 2010)

I don't know if these will help or if this applies to your specialty but the same concept applies for documentation....

*Assistant surgeon or assistant at surgery*

When there is an assistant surgeon or an assistant at surgery, the surgeon of record is listed as the primary surgeon. The surgeon of record is responsible for identifying the presence of the assistant surgeon or assistant at surgery and the *work performed*. In this situation, the assistant surgeon or assistant at surgery does not dictate an operative note. An MD or DO serving as the assistant surgeon will report the CPT codes for those procedures.

http://www2.aaos.org/aaos/archives/bulletin/aug06/coding.asp


If the CPT code has a *“0” status indicator*, the operative note will need to clearly state why the assistant was required and the extent of the work performed by the assistant to support payment. The primary surgeon is responsible for including this enhanced documentation in the operative note. Without such information, billing personnel will find appeal efforts difficult.

http://www.aaos.org/news/bulletin/jun07/managing5.asp

http://surgicalassistant.org/Newsletters/2009_Spring_Newsletter.pdf


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## nyyankees (Jan 19, 2010)

I would get out of that situation as soon as possible. No amount of $$ is worth the stress you're going through. Good Luck!!


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## FTessaBartels (Jan 19, 2010)

*Keep your cool*

Rich,
I feel your pain and frustration, but you MUST keep your cool.  One place to go is HR. They are already aware of the difficulty between you and your supervisor, and apparently have backed you up at least once.  But you really need to present your case with a sort of detached professionalism. Have documentation of your position (Rebecca's links were excellent), be convincing but NOT passionate. If necessary, role-play with a trusted friend.  

Reading between the lines I'm getting the sense that your emotions (frustration, anger) might be showing through. You mention your "passion for doing things right."  Messages delivered with a "confrontational" (to use your supervisor's term) attitude are rarely heard, and the perceived attitude can lead to disciplinary action (including termination). So be as careful about the way you deliver the message as you are about ensuring the accuracy of the message.

You will always come across those people who cannot accept an idea that isn't their own. The most successful people find a way to let the other person buy into the change or even think it is *their* idea. If your supervisor believes you are confrontational, she will be defensive. If you can give her some slack so she can approach her supervisor with a change that is "her" idea, she may be more receptive.  Try going to her with the supporting documents and just say, "Here's some additional information that you might find useful when you take this to your boss. If there's anything else I can help you with, just let me know."  Deliver this message with a smile and a pleasant, helpful attitude. Then leave the room. 

Finally ... all this talking about who said what, when and to whom, and how someone looked after a meeting is distracting everyone in the department from doing their jobs.  I've seen office dynamics like this, and they can turn really toxic.  Do what you can to stop it; try not to let it affect your job performance. 

And keep looking for another position because I sense that in the long-term this will not be a good place for you. That will be their loss, not yours. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## PatriciaCPC (Jan 19, 2010)

First I would like to tell all of you how impressed I am each and every time I read / participate in forum discussions. The support here is truly unsurpassed!!
Rich,
I wish you the best of luck... you are on the right track. Keep your head up, keep in touch with your HR representative, & document everything. One of the best lessons I've learned from my Associate Administrator is when feeling frustrated about an issue - give it a day, sleep on it - the morning will usually bring a clear picture as to how you wish to proceed or approach someone who may be confrontational or unwilling to listen.


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## ercoder65 (Jan 21, 2010)

*Thanks!!*

I want to thank everyone for the advice and support I have received regarding my situation. Its times like these that I am truly grateful for being part of a wonderful association of people, from all different parts of this nation and different backgrounds................you are all truly the best! Thanks again.

Sincerely,

Richard Dinaso


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## LLovett (Jan 21, 2010)

Tessa has a really good point about keeping your cool. I myself am very passionate about doing things the right way and it can be very hard to keep cool. Sometimes impossible for me, that is when I have to stop talking all together and wait until I cool down to respond. 

I see in one post that she is trying to disprove you. I wouldn't take that as a personal attack, even if it is, I think you should go with it. I know you have already looked for all possible options but let all parties involved know this as well. If they find something that proves different from everything everyone else has, awesome, post it so the rest of us can benefit. 

I could be wrong on this but I doubt it, I think you are like me in that it doesn't matter what we do or who presented it as long as it is the right thing to do. I always present things that way. I research until I can't see straight and present all my info, if they disagree with what I have then I ask them to support their point of view. I have no problem in changing the way I do things, as long as it is supported and correct. We all make mistakes, we all make bad decisions, but not all of us learn from them or change our ways. 

Toxic enviroments are harder on you than you think. I envy the people that can leave work at work and just go with the flow even when they know it is wrong. I can't do that. It tends to make my life very difficult. 

Don't take this personally, even if some of it is, and don't let them make this personal. Easier said than done I know.

Laura, CPC, CPMA, CEMC


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## IABallou (Apr 13, 2010)

*PA assts*

I feel your pain!
I also wanted to point out, however, that you need to be aware of what payers actually credential PAs and which ones do not.  In our case, BCBS of OK and Aetna and Cigna do NOT credential PAs.  Therefore, when billing for asst surgeon on those claims, we must use the surgeon's name and then add the AS modifier.

Be sure to check with your carriers before billing so you don't possibly have to repeat.


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