ED Coding and Reimbursement Alert

Question: My group is now using mid-level providers (MLPs) to staff our fast track. Each patient is staffed with a physician. My question comes to procedure billing. If the MLP does a procedure such as an I& D of an abscess or suture, does that get billed under the MLP or under the physician? The debate is because the patient is billed under the physician codes if the physician had face to face time with the patient. If there was no face-to-face time, then it is billed under the MLP at 85 percent of the physician charge. The procedure was discussed with the physician, but was actually performed by the MLP. Some are saying that the doc has to be present throughout the procedure or during "key" moments of the procedure to bill for it, and if the doc is not present then it is billed at the 85% of the Medicare fee schedule instead of the physician rate. Is that correct?

Michigan Subscriber

Answer: The answer is unfortunately black and white. Transmittal 1776 governs the physician supervision of PAs for Medicare. It involves E/M services only, not procedures. Procedures must be billed using the NPP's NPI number and cannot be billed Medicare "incident to" in the ED. A procedure performed by a PA on a Medicare patient may only be billed under the PA's NPI number, lots of bad audit activity currently going here. Your group/billing company should be able to separate out the E/M and the procedure, which requires 2 different 1500 claim forms to go out. The supervisory process for procedures only applies in the teaching setting with residents.

For non-Medicare patients, this construct only applies if the carrier credentials the PAs/NPs this is currently limited to several BCBS carriers and a few other commercial payers but is increasing.