Orthopedic Coding Alert

A certified physician assistant (PA) is a healthcare professional licensed to practice medicine with physician supervision. When working within a physicians office, clinic or hospital setting, PAs can conduct physical exams, diagnose and treat illnesses, order and interpret tests and assist in surgery. In orthopedic and other surgical settings, PAs often are employed as first assistants to the surgeon. Billing and reimbursement for their services is a question of using the right modifiers, knowing the individual carriers policies, providing documentation and obtaining preauthorization.

A Question of the Proper Modifier

Julie McGregor, CMA, is an insurance specialist at Sports Medicine and Orthopedic Specialists, a three-physician practice in Fort Myers, Fla. The practice employs two full-time PAs who see patients and also assist in surgery frequently with procedures such as total knee replacements (27447, arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing) or femoral fractures (27236, open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement [direct fracture exposure]).

McGregor says that the biggest challenge in obtaining reimbursement for PAs when they assist in surgery is knowing which modifier to use for individual carriers. Identifying the correct modifier is by far the biggest question, she says. For Medicare and many private insurers, the HCPCS modifier -AS (physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) is used. Other carriers instruct practices to bill using modifier -80 (assistant surgeon). But because the -80 modifier specifies assistant surgeon, and a PA is not a physician, we dont use this modifier unless instructed by the carrier to do so, says McGregor. She adds that the practice is using the -AS modifier more often to describe the work done.

James Guerra, MD, FACS, of Collier Sports Medicine and Orthopedic Center, a two-physician practice in Naples, Fla., concurs with McGregor about modifiers. Let the carrier tell you which modifier to use, he says. We also call to get preauthorization from private insurers when we know a PA will be used. That way we have a record of the call and authorization to bolster the claim. It makes for fewer denials and appeals in the long run. Guerra also sends a copy of the detailed operative report and a standard form letter explaining that a PA was needed and that there was no qualified resident available to assist. That usually does the trick when it comes to 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 [...]