Orthopedic Coding Alert

Question: I appreciated the article on physician assistant coding and reimbursement in the March 1999 issue of Orthopedic Coding Alert. However, our office has employed a certified orthopedic physician assistant, and according to a Medicare guideline, she does not qualify for a UPIN number because she does not have the same education as a general physician assistant (PA) and is not truly recognized as a PA. I do know it is in the works to get these professionals to be recognized within their field. In the meantime, can I bill for her as an assistant for insurance companies other than Medicare?

Deborah L. Russ, Office Manager
Southeastern Orthopedics

Answer: The coding and reimbursement strategies in the March article referred to physician assistants (PAs), not certified orthopedic physician assistants (OPA-C). For billing purposes as well as cost-effective practice management, its important to distinguish between the two, explains Ron Nelson, PA-C, president of the American Academy of Physician Assistants. Despite the similarity in titles, OPA-Cs are not PAs, even though both are supervised by physicians, he says. PAs are health professionals licensed to practice medicine with physician supervision. OPA-Cs are not.

Below, Nelson clarifies the difference in education, accreditation, and reimbursement between PAs and OPA-Cs.

PAs: PAs are educated in accredited programs located in schools of medicine or allied health, universities, and teaching hospitals. The typical PA student has a bachelors degree and four-and-a-half years of health care experience prior to admission. This background is necessary to prepare the student for the rigorous PA curriculum. For 108 weeksabout two-thirds the time spent in medical schoolstudent PAs have classroom and laboratory instruction in the basic medical and behavioral sciences, followed by rotations in internal medicine, surgery, pediatrics, obstetrics and gynecology, emergency medicine and geriatric medicine.

All states require passage of a certification exam by the National Commission on Certification of Physician Assistants (NCCPA) in conjunction with the National Board of Medical Examiners.

A PA practices medicine within the scope of practice of his or her supervising physician, taking into account any specific restrictions in state law, the PAs experience and expertise, and the physicians wishes about what is to be delegated. Because of their generalist education, a certified PA may practice in any specialty; those who work in orthopedics are called physician assistants in orthopedics.

Medicare covers most services provided by PAs who are legally recognized by the state provided they are currently NCCPA-certified or have graduated from an accredited PA program, Nelson says. (Mississippi is the only state that does not legally recognize PAs.)

OPA-C: OPA-Cs receive specific orthopedic training at community colleges and technical schools. (These programs are not accredited as physician assistant programs.)

The program, which concentrates on teaching technical orthopedic tasks, more closely resembles the training program for surgical technologist or respiratory therapist, Nelson says.

To become certified, the OPA-C candidate must pass a 250-question multiple choice exam given by the National Board of Orthopedic Physician Assistants (recertification is required every four years).

Finally, an OPA-C may practice only in orthopedics.

Medicare does not recognize orthopedic physician assistants as approved providers. After a lobbying effort this past year by OPA-Cs, Medicare determined there is a distinct and significant difference between PAs and OPA-Cs relative to the services provided. Therefore, OPA-Cs are not covered under the Medicare program unless they can meet the requirements of incident to and provide service under the physicians billing number, Nelson says. (These incident to requirements are very specific. For more information, see the March 1999 issue of ORC.)

The only state that completely recognizes OPA-Cs is Tennessee. New York has a specialty classification for PAs that can be used to include OPA-Cs. California recently passed a law that recognizes some OPA-Cs through a grandfather clause.

But state recognition of OPA-Cs as physician assistants would not make their employers eligible to receive Medicare reimbursement for their services, Nelson cautions.

The only way to know if you can bill for incident to with other payers is to check with each of them. Make sure they understand the distinction between OPA-C and PA so they will give you a correct answer. To be on the safe side, ask for their position in writing.