Get Paid for NP and PA Services
Published on Tue Aug 01, 2000
Emergency department (ED) coders must know the rules and regulations associated with nurse practitioners (NPs) and physician assistants (PAs) to be properly reimbursed for their services. From a technical coding standpoint, NPs and PAs are not that different from doctors. They can perform the same procedures and services, and a level five evaluation and management (E/M) code (99285) is always a level five, no matter who does the work. Documentation requirements are just as stringent for everyone.
But in some ways, coders and billers must treat them differently, according to Caral Edelberg, CPC, CCH-P, president of Medical Resource Management in Jacksonville, Fla. There is an interesting divergence of opinion with different payers. Medicare has a very strict set of rules about coding for NPs and PAs.
Medicare requires that the practitioner who performs the service must bill for it, regardless of his or her status. NPs no longer have to be supervised by a physician. But PAs do require physician supervision, and the doctor must then sign off on their charts. Some payers allow doctors to bill for procedures they oversee, but Medicare wont allow it. Even if the physician is hanging over the midlevels shoulder as he or she sutures a wound, he cant bill it, says Jack Turner, MD, PhD, medical director for coding and documentation at TeamHealth, an ED physician staffing firm in Knoxville, Tenn. Medicare has said they will pay the provider who actually performs the service. Supervision of that service is not considered the same as performance of that service.
Not everyone looks at the situation that way. There seems to be a difference between Medicares guidelines and who most payers believe is ultimately responsible, Turner says. Many payers believe that if the physician is there, and he watches and takes part, that hes responsible. So well pay him. Commercial payers dont as a rule recognize independent midlevel practitioners. Some do, particularly with NPs in rural areas.
This dichotomy puts the burden on coders and billers to sort out the details.
For example, a PA sees a patient in the emergency room. The man presents with a 2-cm laceration of the upper arm (880.03). The PA sutures it (12031), and the physician countersigns the chart. This is a fairly simple procedure that requires equally simple coding. But if the patient has Medicare coverage, the PA must bill. If the patient has some other coverage, the physician may have to bill. Consequently, the coder/biller must contact that payers policyholder to complete the coding process.
To bill appropriately, coders must understand the laws regarding NPs and PAs.
Know the Federal Regulations
NP/PA requirements are a common source of confusion, Turner says. Much of that confusion stems from the incident-to concept, a federal guideline that [...]
