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bethsanders

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Hello
I am hoping that someone can give me some feed back with a situation. I am new to Orthopedics. I am going to try and explain the situation as best as I can.

The office had a PA for about a year that had asst. the Dr. in surgeries. When charges were posted the PA was listed as the Dr. and the mod-AS was attached to the CPT. Claims were denied stating out of network so therefore most were billed to the patients.

I started working here in mid August, the company outsourced a person to redo these claims. A void was done and a new claim was created. I have been getting denials that they are dup. claims or insurance companies are sending letters asking why the change.

I guess my question is: Can this be done, if so what is the correct way to handle this. I have so many patient's accounts a real mess now. And the company that our office hired to manage is not answering my questions. Could someone please help me with this. Thanks so much!

Beth Sanders, CPC
 
many questions here, is the practice out of network? was the physician credentialed? does the procedure performed allow for an assistant, did you use an 80 or 81 modifier?
 
No, the doctor is not out of network. But the PA did not have an NPI for most insurance companies. The modifier that was used was AS.

That is the whole issue too, it was not check to see if the procedure allowed an assistant.

I am trying to understand why all of this went on for a year and nothing was done. I believe the outsource person thinks that they can recoup alot of money but I dont see it happening.
 
"When charges were posted the PA was listed as the Dr. and the mod-AS was attached to the CPT"...

Assuming that the carrier does not require the PA to be credentialed and allows a supervising MD, was the claim filed with the MD listed as the supervisor? It looks as if the claim was submitted under then PA's name and NPI rather than the MD's name and NPI. Am I correct? As for the AS modifier, this appears corrrect. (At least for my state). Other states may require a different modifier for an assistant PA.

Do you have the link below? It will tell you if a procedure allows an assistant...

http://www.cms.hhs.gov/pfslookup/02_PFSsearch.asp?agree=yes&next=Accept
 
I do not see this as a happing thing either. If this is not Medicare it should have been either 80 or 81 but if the procedure did not allow for an assist then no deal. Also yu cannot bill as the physician for both the surgery and the assist. So the assist would have had to billed incident to which is possible but still needed to be done correctly. One year after the fact ???? I guess will depend on the carrier. But I am not real keen on the whole bill the patient at this juncture either.
 
mitchellde said:
I do not see this as a happing thing either. If this is not Medicare it should have been either 80 or 81 but if the procedure did not allow for an assist then no deal. Also yu cannot bill as the physician for both the surgery and the assist. So the assist would have had to billed incident to which is possible but still needed to be done correctly. One year after the fact ???? I guess will depend on the carrier. But I am not real keen on the whole bill the patient at this juncture either.
Click to expand...

That's not necessarily true. Many of our carriers state, in their contracts, state that the required modifier is AS. The only carrier, in my locality, that requires modifier 80 is Medicaid. Also...it is stated in our contracts that the assistant surgery is to be filed under a supervising MD with the AS modifier, unless they require the NPP to be individually credentialed...Each state is different with their rules...
 
You are correct in that. My bad. It is very much dependent on who you are billing. But I think we are both on to something as far as billing with the supervising physician. I am willing to bet that both bills went in as the physician without identifying the AS with the supervising physician. It would explain a few things. Either that or the procedure does not allow for an assist or a combination of things. But a year out and just now trying to rebill? I have a hard time with that.
 
Going forward

Here is what we do for PAs assisting in surgery - for commercial payers.

Since most commercial payers do not credential PAs, the claims go in under the supervising MD's name/NPI. When you have a PA assisting the surgeon you have a case where claim # 1 is for the primary Surgeon MD and claim # 2 shows Surgeon MD with AS modifier on the CPT (in OUR billing system the provider is listed as the PA, but when the claim goes out it goes out in the surgeon's name - let's us track these more easily).

They almost always get denied on first submission as "duplicate charge" because few of the payers have software that recognizes the modifier. So we appeal with a letter explaining that the PA assisted the surgeon, attach a copy of the operative report, clearly showing the assist by PA, and voila ... we get paid on appeal.

I don't know why your PA claims would have been denied as "out of network" but clearly, billing the patient was the wrong thing to do. It sounds as if the claims were properly submitted, but an appeal should have been done.

Good luck.

F Tessa Bartels, CPC, CEMC
 
Thanks for all of your input on this. And yes it is a headache. The office that I work for outsourced someone to do this. Yesterday I had received over 100 letters from Medicare seeking a refund on accts that were file with an incorrect provider number. I called MC this morning and was told once the correct information was received then payment would be processed. But first refund needs to be made. To me our A/R is going to look horrible. The dr doesnt know this yet. :( The outsource person did not let me know that I would be getting letters from MC.

The PA was listed as the supervising dr. when billed. It is all starting to come together what happened with this situation and plus the procedure was not looked into to see if it was payable with a AS.

As for me, I would not have messed with it since it has been a year ago that all of this was done. I tried to explain this to the medical management but since I am new with the office I guess my thoughts or suggestions do not count.

Have a great day!
Beth Sanders, CPC
 
Government payers

My previous answer was specific to COMMERCIAL payers.

For government payers (mostly T-19 Medicaid in pediatrics, but for T-18 Medicare as well) ...

Our PAs are credentialed with their own NPI numbers. If they assist the physician - claim No 1 is for the primary surgery; claim No 2 shows the same procedure code but with AS/82 modifier (we're in a teaching hospital) and the PA as the provider, with primary surgeon listed as supervising.

We still occasionally get a denial as "duplicate" ... but a copy of the op note usually clears that up pretty quickly.

If your PA claims are being denied as "out of network" I wonder if your PA isn't credentialed?

Hope that was helpful.

F Tessa Bartels, CPC, CEMC
 
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