ED Coding and Reimbursement Alert

Emergency department (ED) coders must know the rules and regulations associated with nurse practitioners (NPs) and physician assistants (PAs) to be properly reimbursed for their services. From a technical coding standpoint, NPs and PAs are not that different from doctors. They can perform the same procedures and services, and a level five evaluation and management (E/M) code (99285) is always a level five, no matter who does the work. Documentation requirements are just as stringent for everyone.

But in some ways, coders and billers must treat them differently, according to Caral Edelberg, CPC, CCH-P, president of Medical Resource Management in Jacksonville, Fla. There is an interesting divergence of opinion with different payers. Medicare has a very strict set of rules about coding for NPs and PAs.

Medicare requires that the practitioner who performs the service must bill for it, regardless of his or her status. NPs no longer have to be supervised by a physician. But PAs do require physician supervision, and the doctor must then sign off on their charts. Some payers allow doctors to bill for procedures they oversee, but Medicare wont allow it. Even if the physician is hanging over the midlevels shoulder as he or she sutures a wound, he cant bill it, says Jack Turner, MD, PhD, medical director for coding and documentation at TeamHealth, an ED physician staffing firm in Knoxville, Tenn. Medicare has said they will pay the provider who actually performs the service. Supervision of that service is not considered the same as performance of that service.

Not everyone looks at the situation that way. There seems to be a difference between Medicares guidelines and who most payers believe is ultimately responsible, Turner says. Many payers believe that if the physician is there, and he watches and takes part, that hes responsible. So well pay him. Commercial payers dont as a rule recognize independent midlevel practitioners. Some do, particularly with NPs in rural areas.

This dichotomy puts the burden on coders and billers to sort out the details.

For example, a PA sees a patient in the emergency room. The man presents with a 2-cm laceration of the upper arm (880.03). The PA sutures it (12031), and the physician countersigns the chart. This is a fairly simple procedure that requires equally simple coding. But if the patient has Medicare coverage, the PA must bill. If the patient has some other coverage, the physician may have to bill. Consequently, the coder/biller must contact that payers policyholder to complete the coding process.

To bill appropriately, coders must understand the laws regarding NPs and PAs.

Know the Federal Regulations

NP/PA requirements are a common source of confusion, Turner says. Much of that confusion stems from the incident-to concept, a federal guideline that requires physicians to interact with the patient before a midlevel practitioner can get involved. But that rule no longer applies in the ED setting. As long as the physician is on the premises, midlevels can see new patients in the ED from the beginning. And everyone is a new patient in the ED, Turner says.

Here are some rules coders must know:

Federal regulations allow NPs to bill independently of physicians, while PAs must be supervised. But states have been given a lot of leeway to set their own rules. The concept of supervision is defined in many different ways, and some states also require supervision of NPs.
NPs and PAs can perform any medical service required, from splinting a broken arm (29125) to performing CPR (92950).
PAs and NPs must have their own provider numbers if they intend to submit bills.
Medicare pays only 85 percent of the physician reimbursement for work done by PAs or NPs.
The standard supervision and coding laws for PAs dont apply at teaching hospitals where senior physicians work with residents and interns.
Federal regulations address reimbursement, not clinical work, Turner says. They dont talk about the practice of medicine. Theyre very careful to avoid that. Practice regulations are set by state regulations and hospital bylaws. The feds say you must be licensed by the state and perform according to state laws.

Other Regulations

Although Medicare no longer requires the -AN modifier for PA services, some payers still want modifiers, Edelberg says. There can be a coding difference in some payers. Some wont allow you to bill higher than a certain level when a service is performed by a PA. Thats a growing trend. On the other hand, some coders still attach modifiers when they dont have to, says Turner. That will kick the bill out and send it back, delaying things.

Many individual payers have other rules that contradict federal requirements. In general, the stricter law takes precedence in any jurisdiction where it applies.

PAs who are employed by the hospital cannot bill individually. Their services will have to be coded under ambulatory payment classifications (APC) for Medicare but considered part of the facility charge for everyone else, Edelberg says. Youve got situations where independent emergency physicians are billing for services performed by hospital-employed PAs. You cant do that.

Because these laws differ so much from jurisdiction to jurisdiction, coders might want to gather information firsthand. Edelberg advises calling major private payers and Medicaid and requesting NP/PA policies. The American Academy of Physician Assistants (AAPA) maintains a useful list of state guidelines and licensure requirements at its Web site: www.aapa.org. The American Academy of Nurse Practitioners (AANP) also offers information at its Web site: www.aanp.org. State medical boards also can offer guidance, Turner says.

Avoid Fraud

Although Medicares rules are clear and predictable, many physicians and ED staffing networks routinely have doctors sign off on midlevel practitioners charts, saying they agree with the treatment, and bill under the doctors numbers. According to Edelberg, thats Medicare fraud. A physician has to do more than countersign the chart. If they bill wrong, Medicare can nail you. Medicare is aware that there have been problems and abuses.

Another common problem is the practice of some emergency departments and physician groups steering Medicare patients to physicians rather than nurse practitioners or physician assistants, Turner says. Medicare will not allow a two-tiered system of treatment for Medicare patients. In other words, if your hospital or emergency group tries to say that midlevel practitioners cant see Medicare patients, but can see others, Medicare considers that two-tiered.