ED Coding and Reimbursement Alert

Busy EDs across the country rely heavily on physician assistants (PAs). Under the supervision of a single emergency physician, several PAs can do initial patient workups, procedures, and, in more than 45 states, write prescriptions.

However, confusion over changes in the way PA services are reimbursed by Medicare and a clarification from the Health Care Financing Administration (HCFA) prohibiting the billing of PA/physician services in the hospital setting as incident to resulted in many departments scaling back their use of PAs, not using them altogether, or, in the worst cases, continuing to bill for their services incorrectly.

If hospitals and emergency physician groups learn the requirements for reporting and billing these services and follow a few simple guidelines, EDs can improve their reimbursement and use PAs to improve patient care and satisfaction at the same time.

In order to correctly report PA services, the ED coder must be able to reliably distinguish a PA service from a physician service that is performed with minor assistance from the PA. Knowing the new requirements for reporting services involving PAs to Medicare is also essential.

We spoke to representatives from the American Academy of Physician Assistants (AAPA) in Alexandria, VA, to get advice on how EDs should document and report these services.

Forget Incident To

The main thing emergency departments should be aware of is that the concept of incident to does not apply in the hospital setting, and this includes services provided in outpatient departments like the ED, states Ron Nelson, PA-C, AAPA president and the president and CEO of Health Services Associates in Fremont, MI.

Conversely, in the office and clinic setting, services performed by PAs can be coded as a physician-provided serviceand reported on the HCFA-1500 claim form using the physicians own Medicare provider identification number (PIN)if the following criteria are met:

the physician is on-site at the time of treatment;
the physician originally saw the patient for the first visit to the office or clinic;
and the physician sees the practices established patients for any new medical problems.

In these settings, the PA service is seen as incident to (an integral part of) the physicians overall service to the patient.

In the ED, PAs commonly see patientsparticularly in the fast track and urgent care areaswith the supervising physician remaining available for consultation, and reviewing and signing off on the PAs chart. In some cases, the physician may not review the chart until the end of the shift. Many hospital EDs have been reporting these services as physician-performed services under the incident to provision.

The advantages to this are clearphysician services are reimbursed at 100 percent of the fee schedule by Medicare and most other third-party payers, whereas services designated as PA services are reimbursed at a discounted percentage. (See section Reporting PA Services below.)

However, Medicare does not consider the incident to concept applicable in hospitals or nursing facilities and never has, says Nelson.

This has not always been clear, he admits. Billing a PAs ED services under the incident to provision has been a common practice at many hospitals because some Medicare carriers have allowed it in the past. But, HCFA clarified its policy in a memo to its regional administrators on October 28, 1996, which effectively ended this practice.

In the ED, services provided by PAs under physician supervision should be reported as a PA service and are eligible to be reimbursed at 85 percent of the fee schedule, Nelson states.

Note: The above statements apply only to Medicare and the payers that follow its policy. Some other third-party payers may have their own definitions of what constitutes incident to and reimburse PA services at different percentages of their fee schedule.

Reporting PA Services

In the past, a PA service was reported to Medicare under the supervising physicians provider identification number (PIN), but an -AN modifier would be attached to the CPT code to indicate that the PA, not the physician, performed that service.

Medicare also had a confusing mishmash of percentages at which it would reimburse these services if they were reported by PAs. The percentages varied based on the type of service and the setting in which it was performed.
Under the Balanced Budget Act of 1997 (BBA), which took effect January 1, 1998, all PA services are reimbursed at 85 percent of the physician fee schedule. And, PAs are required to bill their services under their own provider numbers.

However, the onslaught of PAs and nurse practitioners (who were also covered under the BBA provision) seeking provider numbers resulted in significant delays, acknowledges Michael Powe, director of government and professional affairs for the AAPA. In addition, many carriers did not have the proper software in place to issue the new numbers, so many PAs are still without PINs.

Some carriers have instructed their providers to continue to bill PA services with the old modifiers while their systems are updated. PAs and emergency groups who employ PAs should check with their local carrier to find out whether or not they should still use modifiers and which modifiers the carrier will accept.

HCFA regulations also allow PAs to hold charges for services provided after Jan.1, 1998, and submit them when they receive their PINs, notes Nelson. They will be due the correct payment plus interest, he adds.

Note: To obtain a provider number, PAs must contact their local Medicare provider representative and request the HCFA 855/98 Provider/Supplier Application.

If a Physician and PA Both Provide Service

However, just because a PA performs part of a patients exam, this does not mean that the service is necessarily a PA service, says Nelson. If the physician performs the substantial portion of the patients evaluation and treatment, then the physician should still bill for the service and be reimbursed at 100 percent of the fee schedule.

This is not the same as billing incident to, says Nelson. The coders should think of it in terms of determining who performed the service? Is it a PA-only service or did the physician perform a majority of the service? If the physician performed the substantial portion of the service, then it should be considered a physician service and reported as such.

But what constitutes a substantial portion?

That is a confusing issue and the AAPA has sought clarification from HCFA with little success, Nelson adds.

In his opinion, Nelson states, a substantial portion means that the physician was involved in taking part of the history, performed at least part of the exam, and was involved in the medical decision-making to determine a diagnosis and treatment plan. Here are Nelsons recommended guidelines to determine whether the physician should report the service:

1. Does the physician document that he or she examined the patient? The documentation must indicate that the physician performed at least part of the patients examination, not just that he or she reviewed the PAs documentation and approved the treatment, says Nelson.

For example, if a patient comes to the ED with a laceration, and the PA sews up the laceration, and the physician comes in afterward and looks at the repair and says to the patient, Mrs. Jones, we have sewn up this laceration. You should be fine and should follow up for suture removal in seven days, then my feeling would be no, the physician could not bill as if it were a pure physician service, he explains.

But, notes Nelson, say a patient presents with possible pneumonia. The PA might do the initial physical exam and order a chest x-ray. The physician may then come in, go over the PAs documentation of the history and physical, look at the x-ray with the PA, repeat the portion of the exam relating to the lungs, and establish a diagnosis of pneumonia and order treatment.

The physicians documentation should state, I reviewed the history and physical, performed this specific physical exam, and I agree with the diagnosis written and I have personally examined this patient, says Nelson. Then, I think you could say that this exam was substantially performed by the physician.

2. Does the documentation indicate physician involvement in establishing a diagnosis? In the first example above, the physician was not involved in diagnosing the laceration. The physician did not see the patient until after the repair was complete. However, in the second example, Nelson notes, the physician went over the information obtained by the PA and even performed a focused exam on the patient to obtain information to establish a diagnosis.

3. Did the physician determine the treatment plan? Under the second example considered above, say the physician spoke to the patient saying, Mrs. Jones, it looks like you have some lower lobe pneumonia. We are going to give you a prescription for an antibiotic, and the PA is going to write this prescription, says Nelson.

Even though the PA writes the prescription, it is the physician who is determining treatment. As long as the documentation supports this, then this would be reported as a physician service.

Medicare Guidelines Dont Agree

Jack Turner, MD, medical director for documentation and compliance for TeamHealth, Inc. in Knoxville, TN, disagrees with Nelson on the ability of the physician to bill for work actually performed by the PA.

Most Medicare carriers will only pay for what the physician actually did, and the documentation must support that the physician actually performed the service, he says. If the PA did the initial workup and documented 25 different systems, but the physician came in and only documented performing an exam of five systems you couldnt bill a level 5, you could only bill a level 4, because that is the portion of the service actually provided by the physician.

In addition, the physician can only report a procedure that he or she performed, he adds. If the physician determines that a laceration needs to be sewn up and directs the PA to do the repair, then he can not report the laceration repair, Turner explains.

This is not true for all states, he acknowledges. In Ohio, for example, the carrier does allow physicians to bill for the entire service if they perform at least part of the history, exam, and medical decision-making, he adds. Their requirements are the same as those for teaching physicians and residents, he notes. Some other carriers may feel the same. But, these are not the federal Medicare guidelines.

Federal Medicare guidelines do allow the PA to take a portion of the history, and TeamHealth physicians can have a PA take the patient history, then relay the information to the physician, who obtains additional information, performs the exam and determines the needed treatment, he adds.

When the PA is a Hospital Employee

These billing requirements become even more complicated when the PA is employed by the hospital, but supervised by an emergency physician who is employed by an outside physician group. If the service provided is a PA service, then the hospital will report the PAs services on the hospitals UB92 form.

However, the physician still supervised the PA and should receive some compensation. In such cases, the emergency physician group must establish contractual arrangements with the hospital to ensure that they will receive reimbursement from the hospital for the service of supervising the hospitals PAs in the ED.