Gastroenterology Coding Alert

The Balanced Budget Act, which was signed into law in August 1997, removed many of the restrictions on Medicare reimbursement for services provided by physician assistants (PAs). Three years later, however, many gastroenterologists are still confused about how to bill for evaluation and management (E/M) visits and procedures handled by a PA.

Although PAs can perform a variety of gastrointestinal procedures, most seem to focus on three main activities, according to Rick Davis, a PA at the University of Florida at Gainesville College of Medicine, Division of Gastroenterology, Hepatology and Nutrition.

1. Performing flexible sigmoidoscopies: Many PAs perform flexible sigmoidoscopies for their practice or for a colorectal cancer screening clinic, says Davis. If the patient needs a biopsy, polypectomy or any procedure that requires sedation, then he or she is referred to a gastroenterologist.

2. Managing chronic hepatitis patients: As the number of patients with chronic hepatitis continues to climb, much of their long-term follow-up treatment is being handled by PAs. The physician assistant will order and review lab tests, adjust the patients medications and perform education and lifestyle counseling, Davis explains.

3. Evaluating new and established patients: Davis primarily handles evaluation and management (E/M) visits with both new and established patients. I take the patients history, perform the physical exam and work up a plan of treatment, he explains.

Billing for Services Under Direct Supervision

Reimbursement for services provided by a physician assistant will fall into one of two categories direct personal supervision and general supervision. According to the Medicare Carriers Manual, Direct personal supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. But the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.

PA services performed under direct supervision will be reimbursed at 100 percent of the standard fee for the procedure, according to Michael Powe, director of health systems and reimbursement at the American Academy of Physician Assistants in Alexandria, Va. The PA must be an employee of the medical practice. The service will be billed under the gastroenterologists provider number, and reimbursement will be paid to the PAs employer.

General Supervision Services Receive 85 Percent

Powe defines general supervision as when the PAs supervising gastroenterologist is available for consultation via electronic communication, such as the telephone. If the gastroenterologist is going to be out of the office and at the hospital for much of the time, the services of the physician assistant will more likely fall under this category of general supervision.

Reimbursement for services provided by PAs under general supervision will be at 85 percent of the standard fee. The Balanced Budget Act states that payments will be allowed for services furnished by PAs in all settings but only if no facility or other provider charges are paid in connection with the service. Payment would be equal to 80 percent of the lesser of the actual charge or 85 percent of the physician fee schedule.

Although the services provided under general supervision are billed under the PAs provider number, Powe says, the PA must still be an employee of a medical practice. Reimbursement will be paid to the PAs employer.

When an established patient calls for an appointment in many gastroenterology practices that utilize PAs, the patient may be asked if he or she wants to see a PA or a gastroenterologist, Davis explains. The E/M visits of those patients who indicate they want to see the PA are considered to be services under general supervision because the supervising gastroenterologist will not necessarily be on the premises and are billed under the PAs provider number. Reimbursement will be at 85 percent of the standard physician fee.

If the patient wishes to see a gastroenterologist or if it is a new patient, he or she would still start the visit by seeing the PA, who will take the patients history, perform a physical examination and develop a suggested treatment plan. The PA then presents his or her findings and treatment plan to the gastroenterologist, who later meets with the patient to further discuss his or her complaint and treatment options.

Screening Flex Sigs and Upper-level E/M Visits

Although many PAs perform diagnostic flexible sigmoidoscopies, Medicare has stated specifically that only physicians will be reimbursed for screening flexible sigmoidoscopies (G0104) provided under the Balanced Budget Acts colorectal cancer screening benefit. Powe believes that there is no good reason for this exclusion, and that the Health Care Financing Administrations (HCFA) Office of Clinical Standards and Quality has indicated that it is reviewing the screening policy.

In the past, PAs also have had some trouble charging for high-level E/M visits. Some carriers dont understand that PAs can bill all level of E/M codes, Powe explains.

A letter in April 2000 from Robert A. Berenson, MD, director of HCFAs Center for Health Plans and Providers to the American Academy of Physician Assistants, addresses the issue of high-level E/M services and says that [t]he Health Care Financing Administration has not established a policy that would prohibit PAs from providing these services. If a PA is authorized by state law to provide such services, the PA may perform this service and the PAs employer may bill the local Medicare carrier for medically necessary services.

HCFAs national policies often are not followed at the local level, however. Just because HCFA says that PA services are reimbursable doesnt mean that all the regional Medicare carriers will do it, Davis notes. It pays to get to know the policies of your state Medicare payer.