Wiki Modifier for P.A. E&M coding

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heatherweinmaster@gmail.com

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Hello All,

I was wondering if anyone could help shed some light on this:

One our Physician Assistants, saw a patient in follow-up. Billed out a 99213, no other procedures done at that visit. The insurance company is UHC, so the P.A. is only billed as rendering, with a supervising physician. This is the denial we received.

"Per payor, when services are rendered by a Certified Physician's Assistant (PA-C), a modifier may be required on procedure code 99213 to denote the services were provided in collaboration with a physician.

Is there a PA modifier that should be attached to E&M codes?

Help!

Thanks
Heather
 
We're coming up with this issue as well. I found this from the UHC website:

https://www.unitedhealthcareonline....ws/June-Interactive-Network-Bulletin-2017.pdf

New Policy – Advanced Practice Health Care Professional Evaluation and Management Procedures Policy Effective for claims with dates of service on or after Sept. 1, 2017, UnitedHealthcare will require physicians reporting evaluation and management (E/M) services on behalf of their employed Advanced Practice Health Care Professionals to report the services with a modifier to denote the services were provided in collaboration with a physician. UnitedHealthcare will accept the modifier SA on claims for these services when provided by nurse practitioners, physician assistants and clinical nurse specialists. In addition, the rendering care provider’s National Provider Identifier (NPI) must also be documented in field 24J on the CMS-1500 claim form or its electronic equivalent. Use of the modifier SA and documentation of the rendering care provider will assist UnitedHealthcare in maintaining accurate data with regard to the types of practitioners providing services to our members.
 
FYI New UHC commercial plan policy on E/M services

Just FYI for any who haven't seen the bulletins. If your practice contracts with United Healthcare commercial plans, in addition to the change requiring the SA modifier and NPI of the advanced practice professional rendering an E/M service reported by a physician, United Healthcare is eliminating the consultation codes for their commercial plans. There is information in the June, July, and September bulletins at https://www.uhcprovider.com/en/resource-library/news.html.

Best wishes,
Cindy
 
Read UHC policy...not clear on this...Does this mean use the SA modifier is present in the office with the PA or NP ?

Any clarification would be much appreciated

Thanks
Rebecca
 
From our med society newsletter, with United Health Care you are to use the SA modifier with all advanced medical personnel ( PA, NP) as to note that they were under supervision by the doctor on staff at that time.
 
so if no physician is in the office at the time of the visit, service is billed without the SA modifier ?
 
My interpretation is that any E&M billed under your PA or NP needs the -SA modifier. It states the -SA will "denote the services were provided in collaboration with a physician." All PA/NP services are "in collaboration" with a physician. This should not affect claims that are billed incident to under the physicians name.
So, it would be used with all E&Ms provided by PA/NP when physician is not present. And any E&Ms provided by PA/NP not meeting incident to even if the physician is in the office (ie - new problem, no established plan of care, etc).
 
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