Wiki Mid-Level Billing

[fairs@sonsa.org]

I'm trying to get some clarification for one of my physicians. He currently has a PA that does the initial exam on some of his patients. They review the exam results, imaging and previous records prior to the physician discussing the treatment plan with the patient. Since the physician is not the one actually performing the exam, it doesn't seem to fit the incident-to requirements, but he is actively involved in the appointment and treatment plan. Any suggestions for the most appropriate way to bill? Should it just be billed under the PA and the physician just doesn't get credit for his part?

Thanks in advance for your input!!

 

[thomas7331]

I think this is a bit of a grey area. The exact language of the regulation is that "there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment..." - it doesn't state that the physician must have done the exam. In my opinion, as long as the physician is performing some portion of the initial face-to-face encounter, such as seeing the patient on the day of the initial visit to formulate and discuss the treatment plan as you describe, then that would qualify the service as 'incident to' even though the PA did the exam portion. Having said that, I could see how this might present an audit risk as some auditors might interpret the statute to mean that the entire initial E&M service should have been personally performed by the physician.

If this is a regular scenario at your practice, it might be a good idea to sample some encounters and run them by an auditor or compliance professional to get their input and make sure you're meeting all the requirements. You could also pose the question to your MAC and try to get a written clarification as to how they see it.

 

[thomas7331]

To add to my previous response, I'd also point out that under the CMS guidelines for split/shared EM services, there is language stating that if "an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed “incident to” if the requirements for “incident to” are met and the patient is an established patient." This does seem to suggest that if the EM service was split between your PA and physician as described in your example, the 'incident to' requirement would only be met if the patient was already established to the provider or practice. Hope that helps clarify some more.