ED Coding and Reimbursement Alert

Question: Our ED has recently received separate billing numbers for our physician assistant (PA). If a patient is seen primarily by the PA but the ED physician did a procedure, would the chart be billed under the physician number? If the physician also saw the patient, but there is no written documentation from him, would it be billed under the PA or ED physician number?

Georgia Subscriber

Answer: There is no incident to in the hospital setting. Therefore, the physician has to perform and document all three key elements and/or any procedures to bill under the physicians provider identification number (PIN) with the exception, as outlined in the AMA/HCFA documentation guidelines, of the review of systems (ROS) and past, family and social history (PFSH). These elements can be obtained by other ED staff. Otherwise, you would bill under the PAs PIN. Medicare will reimburse this at 85 percent of the allowable charge, whereas the physician is reimbursed at 100 percent.

If the patient was seen primarily by the PA, but the ED physician did a procedure, and this scenario was documented as such, the billing would go out with the PAs PIN on the evaluation and management (E/M) code and the physicians PIN on the procedure. If the physician also saw the patient, but there is no written documentation, it doesnt appear that the physician performed all three key elements of the visit. Therefore, it is not possible to have the bill under the physicians PIN. The state licensing board and hospital bylaws will have other requirements regarding PAs, including supervising physician signature requirements. The only hard and fast rules are specific to Medicare.

You will find that commercial health plans usually do not enroll mid-level providers (MLPs), such as PAs. Claims for their services are sent under the supervisory physicians name. Medicaid is different state to state. The Civilian Health And Medical Program of the Uniformed Services (CHAMPUS) issues MLP provider numbers and payment is not changed.

There are distinctly separate rules for Medicare versus private payers, therefore check with your carriers.

For more information on this topic, please see Get Paid for NP and PA Services in the August 2000 ED Coding Alert, page 59.