ED Coding and Reimbursement Alert

Question: Can we bill MD charges for physician assisstant (PA) services in the ED if the doctor is supervising treatment and noting in the documentation that he agrees with PA treatment?

Anonymous California Subscriber

Answer: In most cases, this would be inappropriate. According to the rules established by the Health Care Financing Administration (HCFA) for Medicare, the ED physician can bill only for care that he or she provides to the patient. It would be permissible for a PA to participate in the overall physician service if the documentation by the physician indicates that the physician performed the substantial portion of the service.

This means that the physician performed at least part of the physical examination, established the diagnosis and determined the treatment plan.

For example, a patient comes into the ED with possible pneumonia, the PA performs the initial examination and orders a chest x-ray. The physician likely then would come in, review the documentation of the history and physical, look at the x-ray with the PA, repeat the key portion of the physical exam relating to the lungs, establish the diagnosis of pneumonia and order treatment.

Editors note: For a more detailed description of billing for PA services, please see Correctly Report PA Services in the ED: Incident To Does Not Apply in the May 1999 ED Coding Alert.

Physicians should note that many Medicare carriers will recognize only services actually performed by the physician, and that the physician documents he or she performed, when determining a level of evaluation and management service. Coders should get a clarification from the regional Medicare carrier on what portion of a physicians service may be performed by a PA.

Also note that billing for PA services in the emergency department is different from billing for PA services provided in other outpatient settings, such as physician offices or clinics. In most offices and clinicsthose that are not part of a hospitalthe PA services may be billed under the physicians provider number as incident to the physician service, as long as the physician saw the patient for the initial visit and is present when the PA treats the patient for the same problem. HCFA does not recognize incident to in the hospital setting, however, and this prohibition includes the ED.