Orthopedic Coding Alert

Physician assistants (PAs) can be a valuable asset to orthopedic practices as they perform many of the same services as the orthopedist: prescribing medications, casting fractures, evaluating wounds, ordering x-rays, and assisting in surgery. However, unless you bill correctly for PA services, your practice could be subject to a post-payment review and if overpayment is found, you could be accused of fraud.

The key is knowing when to bill PA services as incident to and when to bill under the PAs own billing number.
Dawn Carpenter, CPC, billing manager, for Ortho Associates of Grand Rapids, MI, offers these general rules to help orthopedic practices bill for PA services:

If the PA provides the service in surgery, use the PAs own billing and UPIN number. Never bill incident to for surgery.

If the PA provides the service in the office, you may either bill incident to or under the PAs billing and UPIN number, depending upon whether the service meets the incident to criteria.

Incident to Rule

Incident to means the PA remains invisible on the claim form, explains Barbara J. Cobuzzi, MBA, CPC, president of Cash Flow Solutions, Inc, in Lakewood, NJ.

You bill as if the orthopedist provided the care, even though the PA actually didunder the supervision of the orthopedist, she says. Thus, the claim form is filed using the orthopedists name and provider number.

Note: Check with your payers and Medicare carrier to find out what modifiers you should append to PA services provided incident to.

Because payers consider this as if the orthopedist performed the service or procedure, Medicare reimburses at 100 percent of the physician fee schedule.

Yet, if you use the incident to rule indiscriminately or inappropriately, you risk an auditors wrath. Carpenter recommends keeping these caveats foremost in your mind:

1. The orthopedist must develop the treatment plan. In order to bill incident to, the physician must perform the first evaluation and establish an initial diagnosis. Then the PA can do the subsequent visits, says Ron Nelson, president of HSA Consulting Group in Freemont, MI, and president of the American Academy of Physician Assistants.

The orthopedist must also first see established Medicare patients who have new medical problems. PAs may then provide the subsequent care, he explains.

Whether the patient is new or established, the orthopedist should not only establish the initial diagnosis but also establish through documentation that he or she continued to supervise the care, adds Cynthia Swanson, coding specialist with Seim, Johnson, Sestak & Quist, a healthcare reimbursement consulting firm in Omaha, NE.

The documentation should clearly show the orthopedists participation in and management of the patients course of treatment, she states.

Note: The ultimate test for incident to billing is, Did the physician perform a substantial portion of the key elements of that billable service? If the answer is yes, then you can bill incident to.

2. PAs must be directly supervised. Under the incident to provision, the physician must be on site, not across the street at the hospital, sources point out. Yet, unless your state law requires it, the orthopedist need not be physically present in the room when the PA is performing the services.

However, as the supervising physician, he or she must be immediately available to the PA for consultation, Nelson explains. The orthopedist doesnt have to be in the room, but must be in the office suite at least.

Swanson adds that the availability by telephone, or the mere presence of the physician somewhere in the institution does not constitute direct supervision.

3. If the PA makes hospital rounds, incident to cant be used. This is one of the most frequent violations of the incident to provision, expert sources state. It can only be used for services and procedures done by the PA in the office, not in a hospital or nursing facility, stresses Nelson.

This doesnt mean your practice cant use PAs to make rounds for orthopedic patients in the hospital. It can. You just cant bill for it and get 100 percent of the physician fee schedule. Otherwise, you will open up your practice to a post-payment review, because you have been overpaid.

Reminder: If you file under a PAs number, Medicare calculates reimbursement at 85 percent of the physician fee schedule.

Swanson points out that having the orthopedist countersign the PAs notes for hospital rounds wont save your practice from possible accusations of Medicare abuse.

If I found a PA note [from services rendered in the hospital] that the doctor had signed, I disregarded it. You simply cant bill incident to in a hospital, says Swanson.

Note: Co-signatures may be required by state collaboration regulations.

If a PA makes rounds, you must bill it as such and get the lower reimbursement at 85 percent. she says.

Note: Reimbursement for all PA services is made directly to the practice. PAs do not receive direct reimbursement.

Thats why every orthopedic practice should obtain billing identification numbers for their PAs, urges Nelson.

Its a widespread belief among practices that they dont need billing numbers for their PA, Nelson says. They believe they can continue to use incident to, because theyre getting paid.

While Medicare carriers wont evaluate incident to on a claim submission, they may indeed ask you to prove it in a post-payment audit.