Orthopedic Coding Alert

Because the orthopedic physician assistant (PA) takes on roles in the office, hospital and operating room, billing can be confusing. When it comes to reimbursement, where the PA works (which state, which setting) is as important as how a PA works.

As for the how, Ron Nelson, PA-C, president of Health Services Associates in Freemont, Mich., says, It is important to distinguish between regulatory and employment issues. The employment issueswhether the PA is compensated as a W-2 (payroll employee) or 1099 (independent contractor)are separate from the legislative ones.

The compensation a PA receives always must be dispersed by (flow through) the physicianthe healthcare provider ultimately responsible for the activities of the PA. The sort of payment arrangement a PA negotiates with a physician is, under current federal and state guidelines for PA function, irrelevant to the role a PA plays in conjunction with a physician.

Regulatory Issues: A states legislation and licensure ultimately determine how a PA can function, which means to fully understand reimbursement for PA services you must have a thorough knowledge of the law of the state in which the PA is working. But Medicare sets the parameters for the minimum amounts of supervision and maximum amounts of reimbursement.

For example, although Medicare policy dictates a PA must always work under physician supervision, the statenot Medicaredetermines how close the physician supervisor must be. Within quick calling distance (immediately available) will do in some jurisdictions. In other states, the physician must be physically present when the PA renders a service.

A PA can provide many services in an office and hospital, including independent evaluation of a patients condition, setting casts and interpreting x-rays. But a PA cannot make a diagnosis; only a physician can do that.

There are complications beyond the state-by-state licensure. Medicare carriers in each state also set specific guidelines.

Since 1998, it has been possible for a PA to obtain his or her own non-physician provider Personal Identification Number (PIN) and, in certain and limited circumstances, to bill under it instead of under the Universal Physician Identification Number (UPIN) of the physician supervisor.

Incident To and Its Opposite: Incident to describes one way a PA works in an outpatient setting. A PA can never work incident to in an inpatient (hospital) setting.

To understand incident to, visualize a PA who is invisible to the payerthat is, when a bill is submitted, the UPIN of the physician is the one recorded. To meet the requirements of incident to, the PA services must be rendered in a way that is integral to the physicians activityfor example, when the PA helps the physician cast a patient. When a PA works incident to, the physician can bill for 100 percent of the allowable charge for the service.

The opposite of incident to is, perhaps unfortunately, not incident to. The latter means the PA is tackling tasks under the mandated supervision of a physician, but the PA is starting and finishing them (e.g., the entire casting procedure, using the appropriate casting code 29000-29799). In an outpatient setting, the PA can bill for the services under his or her own PIN if the PA is certified by the National Commission on Certification of Physician Assistants (NCCPA), PA-C, an option that now applies only to a PA working with a primary-care physician.

Even when billing is done under the PIN of the PA, the payment must flow back to the PA through a physician and the payment must never exceed 85 percent of the physician fee schedule for the service. The Medicare allowable limit varies with the setting. See some examples in the box at left, Examples of Maximum Allowable Charges for Services of a PA.

When there is a billing option, documentation is critical. Since a practice captures more reimbursement when a PA works incident to, auditors want to verify that it is actually the way the PA is working.

Note: The article Avoid Fraud and Abuse Charges: How to Bill for Orthopedic PA Services Correctly on page 21 of the March 1999 Orthopedic Coding Alert takes a close look at how to bill correctly for orthopedic services provided by a PA in an office.

Operating RoomA Different Set of Rules

When a PA works in an operating room (OR), he or she falls under guidelines that govern the OR and supercede those for other settings. The PA might be working in the OR in one of three capacities: assistant at surgery, member of surgical team but not an assistant at surgery, or not a member of the surgical team and not an assistant at surgery. When the PA works as an assistant at surgery (technical surgical assistant, TSA), there are billing implications for the PA.

Linda L. Classic, vice president of corporate compliance at Palomar Pomerado Health System in San Diego, gives an overview of the situation. Incident to billing is not allowed in hospital settings as per Medicare policy, she says. Therefore, a PA acting as an assistant at surgery in the hospital setting has no option but to bill under the PAs PIN. Also, most Medicare carriers require the PA to attach the modifier -AS (physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) to their billing.

Examples of when the PA might assist include wrist surgery (25300, tenodesis at wrist; flexors of fingers) amputation (25922, disarticulation through wrist; secondary closure or scar revision) and leg surgery (27602, decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment[s]). In each case, the CPT code would be appended with the -AS modifier.

Always check with each state for its regulations identifying the scope of practice and supervision guidelines for PAs and check with the local Medicare carrier for their billing instructions, as these can differ state to state and carrier to carrier, Classic adds.

Nelson agrees, If a hospital has surgical residents, they must assist first, and only if they are not available can a TSA [which may or may not be a PA] assist. Nelson says if a hospital has a surgical residency program, but it can document that no qualified residents were available for a particular surgery, a PA can assist.

Modifiers -80 and -82: When the PA bills as an assistant at surgery, the modifier -80 (assistant surgeon) must be appended to the CPT code for the surgical procedure in addition to the modifier -AS. (The surgeon submits the same code for the procedure without the modifiers.)

If there are surgical residents and none of them are available, a PA may be used as a technical surgical assistant. In this case, the modifier -82 (assistant surgeon [when qualified resident surgeon not available]) should be used instead of modifier -80.