Pulmonology Coding Alert

Question: I enjoyed your article last month about advanced practice providers. We are currently evaluating whether to bring in a PA to help because we’ve gotten pretty busy. In your article, it said that under CMS rules, the APP can provide services that were part of the “normal course of treatment established by the physician.” Does that mean the APP cannot see new patients?

Codify Subscriber

Answer: The answer depends on the state scope of practice laws where you are, but in most cases, PAs can see new patients. The CMS rule that was cited in the APP article referred to incident-to services, and billing under an established plan of care is one of the many requirements of incident-to billing.

Background: If the PA performs services under incident-to guidelines, the visits are billed under the physician’s identification number and the practice can collect 100 percent of the fee schedule amount of the charges. However, you aren’t required to report the PA’s claims as incident-to. You can instead bill under the PA’s own NPI and, in most cases, collect 85 percent of the fee schedule amount instead.

Therefore, if your state scope of practice laws allow PAs to treat new patients and you are comfortable reporting his or her services under the PA’s own NPI, then you aren’t restricted to reporting the PA’s services for established patients only.