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FAQ - Reimbursement

Can a PA see a patient and bill Medicare without the patient being seen by the physician as well?

For all the most up to date information on Reimbursement for Medicare, Medicaid, Worker's Compensation and Private Pay Plans:

Can a PA's services to a new (first visit) Medicare patient be billed under the "incident to" billing provision?

Is there a state law regarding reimbursement for PAs in surgical first assisting?

Can my local Medicare carrier impose rules that are more restrictive than national Medicare policy?

Can a PA working as a First Assistant in a teaching hospital bill for services?

Can PAs with a Temporary license (awaiting passage of the NCCPA exam and full licensure) bill Medicare?

Can a PA write a prescription for a power mobility device (PMD) under Medicare guidelines?

What has Medicare done to make it easier for PA's and others to assist in natural disasters like Hurricane Katrina?

How can I maximize my reimbursement?

Does a PA have to have a Medicaid provider number?

My office informed me they can not bill for PA services if the physician is not on site when a PA is working. Is this true?

A local CMS carrier informed a Urologist that they had to see all new patients and patients with new problems, and that a PA could only do follow up. Is that true?

Can PAs be reimbursed for the initial visit of a patient in a Skilled Nursing Facility (Nursing Home)?

My employing physician is expressing concern that our Medicare reimbursements will be affected if he/they don't co-sign my Medicare patient charts in the office. Can you clarify this issue for me?

Can I see patients with my physician in a hospital under a "shared visit" by Medicare rules?

Can surgical PAs in single/group physician-owned practices become registered with BCBSF as Surgical Assistant Owned Practices?

Are PAs allowed to be self-employed with a supervising physician listed with the Board of Medicine, and have the Medicare reimbursement checks come directly to my home address, which would also be covered by an occupational license?

Surgical assist seems to come under such scrutiny, when seemingly any other person may set up a corporation to bill, ie: midwives, physical therapists, etc. Do you have any up to date information regarding PA owned business?

My question to you is if the Medicare patient were to be seen by the PA only, and using my NPI number, would this be an acceptable way to bill?

Double Billing Patient?

 

 

Can a PA see a patient and bill Medicare without the patient being seen by the physician as well?

PAs can personally perform any new patient Medicare visit. They can also personally perform and bill for consults. There does not need to be physician contact with the patient.

Legal supervision by state guidelines must be maintained (electronic or tele-communication) and the service should be billed under the PA's name and NPI number. Bill the full physician rate and Medicare will pay at 85 percent of the physician rate.


For all the most up to date information on Reimbursement for Medicare, Medicaid, Worker's Compensation and Private Pay Plans:

http://www.aapa.org/your_pa_practice/reimbursement/resources.aspx

Can a PA's services to a new (first visit) Medicare patient be billed under the "incident to" billing provision?

No. For a medical practice to bill for medical services provided by PAs under the "incident to" provision, the following criteria must be met:

The service must be one within the PAs scope of practice and in accordance with state law.

The service must be one that is typically performed in the physician's office.
The supervising physician (or physician members of the same group) must be in the suite offices when the PA renders the service.

The physician must personally treat the patient and establish the diagnosis on the patient's first visit to the practice. The physician must also treat established patients who come to the practice with a new medical condition.

"Incident to" requires that the physician treat new Medicare patients or established patients with new medical problems. PAs can provide follow-up care for established patients with established problems under this provision.

Medicare does not require that PAs bill under the "incident to" billing provision. PAs can always treat all Medicare patients (new or established with a new medical problem) and bill under their own provider numbers. Reimbursement is made to the employer at 85% of the fee schedule and state law determines supervision requirements.

Billing under the PA's own provider number allows PAs to see new Medicare patients, patients when the physician is off site, or established patients with new problems.

Improper use of "incident to" may lead to fraud and abuse allegations. In addition, "incident to" may be eliminated as a billing mechanism by the Medicare program in the future. You may contact the AAPA for additional assistance.

(This information is from the AAPA News, February 28, 2001 issue)


Is there a state law regarding reimbursement for PAs in surgical first assisting?

Yes. Chapter 627.419, paragraph (6) of Title XXXVII relating to Insurance Rates and Contracts provides for reimbursement of physician assistants who are assisting in surgery.

Can my local Medicare carrier impose rules that are more restrictive than national Medicare policy?

Local Medicare cariers must follow national coverage decisions (NCD). NCDs are developed by the Center for Medicare and Medicaid Services (CMS) to describe circumstances for medicare coverage of a specific medical procedure or device. NCDs generally outline conditions for determining whether a service is covered based on federal law. Once an NCD isa issued as a CMS program instructioin, it is binding on all Medicare carriers.

Local Medicare carriers can, however, develop local medical review policy (LMRP) in the absence of specific statute, regulations, or national coverage policy or as an adjunct to a national coverage decision. In the absence of national policy, LRMPs specify criteria that describe whether the service is covered and under what clinical circumstances it is considered to be reasonable, necessary, and appropriate. LRMPs cannot override or conflict with NCDs. LRMPs are developed by individual Medicare carriers and are typically state and company specific.

When developing an LMRP, the Medicare carrier must solicit comments and recommendations on a policy from the medical community before it is implemented. This may be by contacting health professional organizations, other Medicare carriers or medical directors, review organizations, and the Carrier Advisory Committee. Draft LRMPs for your state can ve viewed on the Web at www.DraftLRMP.net.

LRMPs that have gone through the review and comment process and are being utilized can be accessed online at www.lmrp.net. These Web sites are updated monthly. In addition, CMS requires that Medicare carriers publish any changes in policy immediately in their policy bulletins.

There are times when local Medicare carriers publish policies that are in conflict with national policy. AAPA's reimbursement staff works with state academies and the Medicare carrier to help resolve these discrepancies. If you become aware of an LRMP that appears to be more restrictive for PAs than national policy, contact the AAPA staff at 703.836.2272, Ext. 3219 or 3218.

This information is from the AAPA News, August 15, 2002.


Can a PA working as a First Assistant in a teaching hospital bill for services?

PAs in teaching hospitals may be paid by Medicare as long as a statement is made that "no qualified residents are available" when the claim is filed. Or it can be a simple cover letter to the claim form, but this is not required under normal cicumsances. This is applicable in a all areas. All that needs to be provided on the HCFA 1500 form is the modifier "82", which is attached at the end of the CPT code.

Can PAs with a Temporary license (awaiting passage of the NCCPA exam and full licensure) bill Medicare?

No, you cannot be paid by Medicare until you are fully NCCPA certified.

Can a PA write a prescription for a power mobility device (PMD) under Medicare guidelines?

Yes. CMS has made changes to the method in which Medicare beneficiaries obtain access to power operated vehicles (POVs) or power mobility devices (PMDs) such as power wheelchairs and scooters. The requirement that an authorized health care professional provide the beneficiary with a certificate of medical necessity (CMN) before a PMD is authorized has been eliminated per a CMS interim final rule. A patient?s need for a PMD will be demonstrated by the health care professional and documented in the patient?s medical record as part of a normal evaluation and management (E/M) visit. CMS will pay for the E/M visit, and will also allow a payment of approximately $21 when the health care professional writes a prescription for the PMD and sends supporting documentation to the equipment supplier.

In an attempt to reduce the over-utilization and fraudulent prescribing of PMDs, the Medicare Modernization Act mandated that a patient have a face-to-face medical visit before a PMD is prescribed. The CMS regulations state that the face-to-face visit must be with a prescribing physician or treating practitioner. PAs are specifically included as treating practitioners for prescribing PMDs. Additionally, CMS has eliminated its requirement that allowed only a specialist in physical medicine, orthopedic surgery, neurology or rheumatology to prescribe PMDs, unless a specialist was not reasonably accessible. It should be noted that the elimination of the CMN applies to PMDs and manual wheelchairs, but not to other types of durable medical equipment such as hospital beds, oxygen tents, prosthetics, orthotics, etc.

What has Medicare done to make it easier for PA's and others to assist in natural disasters like Hurricane Katrina?

Medicare Coverage Requirements Eased in Hurricane-Impacted Areas:
Due to the hurricane-related displacement of many residents in the states of Louisiana and Mississippi, the Centers for Medicare and Medicaid Services (CMS) has suspended many of its traditional Medicare and Medicaid coverage policy requirements in order to help facilitate the provision of medical care to beneficiaries. CMS is assuring facilities and health care professionals treating displaced individuals that the normal requirements for documenting and verifying a patient?s eligibility will be waived and the presumption of eligibility should be made. Federal Medicaid officials are working with state Medicaid agencies to coordinate payment of interstate claims. The following policies covering hurricane-related displaced individuals are presently in effect:

Health care providers that furnish medical services in good faith, but who cannot comply with normal program requirements because of Hurricane Katrina, will be paid for services provided, and will be exempt from sanctions for noncompliance, unless it is discovered that fraud or abuse occurred.

Crisis services provided to Medicare and Medicaid patients who have been transferred to facilities not certified to participate in the programs will be paid.

Programs will reimburse facilities for providing dialysis to patients with kidney failure in alternative settings.

Medicare contractors may pay the costs of ambulance transfers of patients being evacuated from one health care facility to another.

Normal prior authorization and out-of-network requirements will also be waived for enrollees of Medicare, Medicaid, or SCHIP managed care plans.

Normal licensing requirements for doctors, nurses, and other health care professionals who cross state lines to provide emergency care in stricken areas will be waived as long as the provider is licensed in their home state.

Certain HIPAA privacy requirements will be waived so that health care providers can talk to family members about a patient?s condition even if that patient is unable to grant that permission to the provider.

Hospitals and other facilities can be flexible in billing for beds that have been dedicated to other uses; for example, if a psychiatric unit bed is used for an acute care patient admitted during the crisis.

Hospital emergency rooms will not be held liable under the Emergency Medical Treatment and Labor Act, also known as EMTALA, for transferring patients to other facilities for assessment, if the original facility is in the area where a public health emergency has been declared.

More information about CMS emergency relief activities, including a detailed explanation of billing and payment policy revisions and phone numbers for the state medical assistance offices, can be found atwww.cms.hhs.gov/katrina. Frequently asked questions and answers on the site will be updated daily.


How can I maximize my reimbursement?

This information is reprinted from Medscape.

Tips On Maximizing Reimbursement


Does a PA have to have a Medicaid provider number?

A provider is not mandated to have a Medicaid provider number. However, if a PA performs a service for a Medicaid participant, the PA must have his/her own provider number. The service is to be billed using the PAs number unless the physician performs the majority of the service and documents as such. Just like Medicare.

The Agency frequently performs ?spot? audits which require sending the patients notes. Documentation is crucial. They will fine, withhold payments and potentially dis-enroll any provider who bills improperly (physician number instead of the mid-levels). This is one of the quality assurance issues they look for.

A provider number and rate schedule can be obtained thru the Agency?s web site. The process is quite arduous, many forms, fingerprinting and biannual re-enrollment.


My office informed me they can not bill for PA services if the physician is not on site when a PA is working. Is this true?

They are incorrect. Medicare and Medicaid have always stated that PAs could see and bill for ALL new patients. Private carriers including Workers Comp also pay for PA services but they usually state to bill out under the supervising physicians NPI number. This includes first surgical assisting. Here are some links that may be helpful:

http://www.aapa.org/gandp/3rdparty.html#PAcoverage

http://www.aapa.org/gandp/issuebrief/3rdparty.pdf

http://www.aapa.org/gandp/priv-insur.html

And if you are an AAPA member, go here and these are the 6 major private carriers in Florida:

http://www.aapa.org/members/gandp/private-pdfs/florida-pp.pdf


A local CMS carrier informed a Urologist that they had to see all new patients and patients with new problems, and that a PA could only do follow up. Is that true?

No, this is not correct.

Please see the two attachments, supplied by Michael Powe of the AAPA. The first is a Reimbursement Summary put together by AAPA. See page 2 of the document, titled Supervision Guidelines, and page 3, titled Billing Medicare in the Office/Clinic Setting. Both sections state that the physician need NOT be physically present when a PA delivers care.

The second document is from the Medicare's Carrier Manual . See the bottom of page 4, Section C, titled Supervision.


Can PAs be reimbursed for the initial visit of a patient in a Skilled Nursing Facility (Nursing Home)?

PA's have never been allowed to do the initial SNF visit or certification. This is a Medicare rule, not Florida rule; Please see the link below for more information:

Medicare Claims Processing Manual

(See Chapter 12 - Physicians/Nonphysician Practitioners)


My employing physician is expressing concern that our Medicare reimbursements will be affected if he/they don't co-sign my Medicare patient charts in the office. Can you clarify this issue for me?

That is simply not true. There is NO requirement by Medicare, Medicaid or Tricare that states the physician must sign anything for PA reimbursement when seeing patients in a clinical setting. Even private carriers have changed their minds recently and only sometimes may require a co-signature.

Keep in mind that there are several different sets of rules all playing at the same time. In Florida, after July 1st, 2009, there is no longer a legal requirement for physician co-signature to "prove supervision." Of course, that co-signature never proved anything but record keeping. It had nothing to do with reimbursement. However, per AAPA staff (still as of August 2009), there is a Medicare requirement for chart co-signature when PAs discharge patients from the hospital setting (discharge day management/summaries, or when a patient is released from ?outpatient hospital departments? such as the ED). Medical Staff By-Laws often have written policy on these requirements. Although it's true that a hospital may make their own requirements internally, be real clear on the rules in Florida and nationwide. Your hospital may make slightly more restrictive policy if it does not restrain trade of any professional.


Can I see patients with my physician in a hospital under a "shared visit" by Medicare rules?

Effective Jan. 1, 2006, Medicare stopped allowing PAs (or NPs) to bill a consult as a shared service. This means that PAs and physicians can't combine their work as part of a consult and bill everything under the physician with payment at 100 percent.

If the PA does the majority of the work then the consult service should be billed under the PA even if the physician co-signs the chart and reviews the PA's work, or even adds information to the patient's chart.


Can surgical PAs in single/group physician-owned practices become registered with BCBSF as Surgical Assistant Owned Practices?

Yes... this was clarified by Reimbursement Committee Chair Hamilton Boone in July 2009. In addition, all PA owned medical clinics will be considered for contracting based on the number of BCBSF clients in the clinics catchment area. The contact number for contracting registration is:

1-800-727-2227, #4,#2

Contact Reimbursement Chair Hamilton Boone for further information.


Are PAs allowed to be self-employed with a supervising physician listed with the Board of Medicine, and have the Medicare reimbursement checks come directly to my home address, which would also be covered by an occupational license?

Medicare has a rule that does NOT allow reimbursement checks to made directly to PA's. They must have a listed supervising physician, must have a legal address where they list as doing business (usually that will be the supervising doc's office) and they must have their own NPI.
Take a look at these resources:
http://www.aapa.org/advocacy-and-practice-resources/practice-resources/e...
http://cms.hhs.gov/transmittals/downloads/R1744B3.pdf.
http://www.aapa.org/news/26--general-?start=70
http://www.aapa.org/news/26--general-?start=60

Surgical assist seems to come under such scrutiny, when seemingly any other person may set up a corporation to bill, ie: midwives, physical therapists, etc. Do you have any up to date information regarding PA owned business?

The simple answer is, it's quite complicated!! Medicare made a federal law over 25 years ago that PA's can not receive direct payment from Medicare, period.This has been challenged numerous times without success. The issue of ownership comes back at the state level with Florida ownership laws. You must have a physician in your S-Corp. LLC, INC whatever with a NPI billing number. The private carriers may allow credentialing as well. Take a look at these links:

http://www.aapa.org/advocacy-and-practice-resources/practice-resources/p...

http://www.facs.org/ahp/pubs/2011physasstsurg.pdf

http://aapa.org/advocacy-and-practice-resources/reimbursement/medicare/8...


My question to you is if the Medicare patient were to be seen by the PA only, and using my NPI number, would this be an acceptable way to bill?

Intro to question: Up until recently, I would see patients along side my SP and would only ask my SP to see the patient if I had a question or if the patient specifically asked to see him. Now I am being instructed that I can only see patients if they are a follow up and have previously had a plan of care established for Medicare patients to bill under incident to billing policy. Additionally, when seeing patients in the office, there is no way to trace it back to the PA who saw the patient unless at the end of the document I state that I evaluated the patient. Now, one of my supervising physicians has instructed me to state that I am the scribe and not the provider evaluating the patient. I feel that my role is now being understated by using this terminology. Is this a necessary statement?

Medicare would say that as a PA, you can and should see any and all Medicare patients (new and established) and then bill them with your NPI, period.

Medicare would also state that when the physician sees the patient during the same visit by the PA, whoever documents the most personal work should bill under their NPI number. That means that if the doctor wants to take credit for billing that visit, he/she MUST see and lay hands on the patient, exam them , ask their own questions, arrive at a working differential diagnosis and establish their own plan of care. Then they sign and bill under their own NPI.

As for a PA acting as a scribe, Medicare says...NO!!!! PA's are too valuable to act as a scribe, which by definition,must write down EVERYTHING the doctor says and does, CANNOT contribute anything to the history or exam and MUST sign their name and credentials as ....Scribed by..blah, blah...PA-C.

Now the counter argument for the so-called 15% revenue loss is: the doc and PA should operate as autonomously as possible to increase the volume of patients AND provide faster access to care and improved continuity of care.

Lastly, as for "incident to" services under Medicare:

Patient must be seen sometime before and have an established DX and Plan of care. The next time they return, can be seen by the PA, he/she must follow the doc's plan of care AND the doc (or any responsible doc) MUST be in the office period. They do NOT even need to see the patient or even talk to the PA, just accept the medical-legal liability. That visit is billed under that doc's NPI number and called Incident to".


Double Billing Patient?

Question: Can a PA that works for an internal medicine physician who sees a patient as an initial visit or follow up visit, refers this same patient to a pulmonologist, where she is the PA for the pulmonologist as well, and then sees the same patient on the same day in the next hour in the same room as a pulmonary consult and bills for both services at 85% under two separate supervising physicians?

The simple answer is NO. The AAPA's Reimbursement Expert gave us his official opinion, which is as follows:

I don?t think any Medicare carrier would pay the claim due to 1) the interpretation of the 3-year rule, and 2) the use of the 97 (PA taxonomy code system) on a claim form. Bottom line is that the scenario doesn?t pass the ?smell test? and I would not want to have to defend the claim to a payer or auditor.

In addition, there is a mention of a pulmonary consult. We recognize that Medicare will not allow for the billing of consult codes




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FAPA Vision: Fully integrate PAs into every aspect of health care in Florida.


 

 

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