Neurosurgery Coding Alert

Physician assistants (PA) often are used as first assistants to the neurosurgeon. Sometimes neurosurgeons do not know the way to ensure proper reimbursement for the PAs services. By using the right modifiers, knowing the individual carriers policies, providing documentation and obtaining preauthorization, you can make sure you are billing correctly and receiving the payment you deserve.

A certified PA is a healthcare professional licensed to practice medicine with physician supervision. When working within a neurosurgeons office, clinic or a hospital setting (wherever they are supervised by a neurosurgeon), PAs in most states may take histories and conduct physical exams, order and interpret tests, handle documentation, assist in surgery and conduct general patient follow-up, among other services.

Michael Powe, PA-C, of the Government and Professional Affairs Department of the American Academy of Physician Assistants in Alexandria, Va., says that the Balanced Budget Act of 1997 expanded the PAs ability to provide care in all settings. But the word has been slow in getting out there with some carriers, says Powe. The neurosurgeon and the PA must understand the PAs scope of practice in his or her particular state and be prepared to advise carriers on this important issue.

Powe gives just one example of the benefits of employing a PA in a neurosurgical setting: If a neurosurgeon uses a PA for services such as postsurgical rounds, which already are paid for under the global surgical package of a procedure, the neurosurgeon can be freed up to go back to the office or see new patients and generate new revenue.

Use the Proper Modifier

James Piotrowski, PA-C, president of the Association of Neurosurgical Physician Assistants, a PA in practice with Neurosurgical Associates of Crystal, Tenn., says that most procedures performed by neurosurgeons require the services of a first assistant. But a second surgeon is not always necessary. A PA often will perform openings and assist with diskectomies (63075, diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy), laminectomies (63045, laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], (e.g., spinal or lateral recess stenosis)], single vertebral segment, cervical), craniectomies (61518, craniectomy for excision of brain tumor, infratentorial or posterior fossa), and more, Piotrowski says. I close everything including skull surgeries and I assist in instrumentation. It is pretty inclusive.

Powe stresses the importance of selecting the proper modifier to identify the services of a PA assisting in surgery. Medicare has eliminated all of its HCPCS modifiers for PAs except the -AS modifier (physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) for first assisting. Powe says that there are a few non-Medicare carriers that use the -AS modifier but it is not typical for most private carriers.

Powe reports that although many third-party payers will have the PA use the same codes as the neurosurgeon and append the -80 modifier (assistant surgeon), this requirement is not consistent across all payers or even within the same insurance company across different regions. Because the -80 modifier specifies assistant surgeon and a PA is not a physician, some carriers may hold claims and delay reimbursement or issue denials when this modifier is used.

We recommend that it is always important to talk to the local carrier to find out what their rules are for submitting claims, says Powe. It is important early on to see if there are specific enrollment criteria and credentialing requirements for a PA who is working in the surgical unit or in the office environment. Powe urges the neurosurgeon to talk to provider relations of that company to see how claims involving a PA are billed, whether the claim is for the PA first assisting or providing any other services. That should eliminate any of the confusion on how to submit a claim and what modifier to use, Powe adds.

Most times, the PA also will submit a claim with a copy of the operative report, which states quite clearly how the PA assisted in the operating room, Powe adds. A standard form letter explaining that a PA was needed also may help to reduce denials and appeals. Calling a carrier to get preauthorization whenever a PA will be used in surgery also should speed up reimbursement.

When Is a PA Used?

Emily Hill, PA-C, president of Hill & Associates, a physician reimbursement and coding firm in Wilmington, N.C., spells out some of the rules for reimbursement of assistants at surgery as outlined in the Medicare Carriers Manual.

Payment is made for an assistant at surgery when one or more of the following conditions are met:

1. the medical necessity for an assistant has been
demonstrated;
2. the surgery requires an assistant in more than 5
percent of the cases nationally;
3. the assistance at surgery is performed in a hospital where no approved teaching program has been
established.

Nancy Hughes, vice president of communications and information services for the American Academy of Physician Assistants (AAPA), a national professional society representing PAs, clarifies some of the restrictions on PAs in teaching hospitals. In general, says Hughes, payment is not made for first assisting when the service is provided in a teaching hospital that has a training program related to the particular surgical procedure and a qualified resident is available. But, she continues, if the teaching hospital has no qualified resident available or, if the primary surgeon has an across-the-board policy of not using residents, Medicare will cover the services of a PA first assistant.

What to Expect for Reimbursement

When a neurosurgeon performs a spinal surgery that requires instrumentation (22840, posterior non-segmental instrumentation, [e.g., Harrington rod technique], pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation), a PA often is used as first assistant at surgery.

According the AAPA, there are set percentages for which practices can anticipate being reimbursed for their PAs in surgery. Hughes explains some of the rules. Coverage for PAs who are first assisting at surgery, says Hughes, is provided at 85 percent of the physicians first-assisting fee. Medicare will reimburse a physician who first-assists at the rate of 16 percent of the primary surgeons fee. But PA first assists are covered at 85 percent of 16 percent (or 13.6 percent of the primary surgeons fee).

Private insurers rates will vary from this percentage by a point or two in either direction, up to approximately 20 percent. Hughes adds that in all cases, reimbursement payments for services provided by a PA are made to the practice, even when using the PAs provider number. All billing is handled by the practice, not the individual PA. For practices where the PAs are full-time staff members, the practice bills for the PAs assistance along with the bill for surgery. PAs usually are salaried staff members, so there is no additional cost to the practice, regardless of whether the PA assists in two or 20 surgeries per week.

The American College of Surgeons (ACS) publishes a helpful reference guide, Physicians as Assistants at Surgery. The guide lists every CPT 2000 surgical code, and whether a first assistant is required almost always, some of the time or almost never. Although the guide refers to the use of physicians and not PAs as first assistants, it is still helpful in justifying the use of a first assistant in surgery. The guide can be downloaded at www.facs.org/
about_college/acsdept/socio_dept/se_pubs/sepubs.html or ordered from ACS by phone at (312) 202-5150.

Hughes says that Medicare covers the first assist fees for most major surgical procedures but has a list of approximately 1,900 CPT codes for which a first assistant at surgery will not be reimbursed. These code restrictions apply to both PAs and physicians, says Hughes. A list of the affected codes is available from a local Medicare carrier or in Section 5039 of the Medicare Carriers Manual. Hughes says that most private carriers will reimburse for the services of a PA as a first assistant, but some will reimburse only when the first assistant is a physician. Coverage guidelines vary, she says. Also its important to contact the payer for details on their specific policies.