Ob-Gyn Coding Alert

Question: A physician assistant (PA) in our practice recently performed a colposcopy and cervical biopsy on a 17-year-old patient after a Pap smear indicated the presence of abnormal cells. How should we report this? Should this be billed "incident-to"?

Indiana Subscriber

Answer: Increasingly, nonphysician practitioners (NPP) such as PAs and nurse practitioners (NP) are performing minor surgical procedures for a range of gynecological symptoms and conditions. Many PAs, for example, are trained to perform vulvar and cervical biopsies and to obtain endometrial samples.

Incident-to billing, however, is a Medicare concept that may not have been adopted or adapted by private insurers. If this is a Medicare patient, you would need to apply the incident-to rules. In other words, the patient cannot be new to the practice on the day of the procedure, the physician must be in the office suite when it is performed, the procedure must be within the NP's or PA's state scope of practice, and the physician must already have established a plan of care for this patient.

If this is not a Medicare patient, you should ascertain the specific rules for each payer and get these rules in writing. Find out if 1) the payer recognizes the NP or PA as a qualified provider of care for the procedure (and the insurance company is free to decide what not to allow, even if the state practice act allows the procedure), 2) it permits the NP or PA to bill the procedure as if the physician performed it, and 3) are there any other requirements for billing the service when not performed by the physician.