Orthopedic Coding Alert

A certified physician assistant (PA) is a healthcare professional licensed to practice medicine with physician supervision. When working within a physicians office, clinic or hospital setting, PAs can conduct physical exams, diagnose and treat illnesses, order and interpret tests and assist in surgery. In orthopedic and other surgical settings, PAs often are employed as first assistants to the surgeon. Billing and reimbursement for their services is a question of using the right modifiers, knowing the individual carriers policies, providing documentation and obtaining preauthorization.

A Question of the Proper Modifier

Julie McGregor, CMA, is an insurance specialist at Sports Medicine and Orthopedic Specialists, a three-physician practice in Fort Myers, Fla. The practice employs two full-time PAs who see patients and also assist in surgery frequently with procedures such as total knee replacements (27447, arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing) or femoral fractures (27236, open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement [direct fracture exposure]).

McGregor says that the biggest challenge in obtaining reimbursement for PAs when they assist in surgery is knowing which modifier to use for individual carriers. Identifying the correct modifier is by far the biggest question, she says. For Medicare and many private insurers, the HCPCS modifier -AS (physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) is used. Other carriers instruct practices to bill using modifier -80 (assistant surgeon). But because the -80 modifier specifies assistant surgeon, and a PA is not a physician, we dont use this modifier unless instructed by the carrier to do so, says McGregor. She adds that the practice is using the -AS modifier more often to describe the work done.

James Guerra, MD, FACS, of Collier Sports Medicine and Orthopedic Center, a two-physician practice in Naples, Fla., concurs with McGregor about modifiers. Let the carrier tell you which modifier to use, he says. We also call to get preauthorization from private insurers when we know a PA will be used. That way we have a record of the call and authorization to bolster the claim. It makes for fewer denials and appeals in the long run. Guerra also sends a copy of the detailed operative report and a standard form letter explaining that a PA was needed and that there was no qualified resident available to assist. That usually does the trick when it comes to reimbursement.

When Is a PA Used?

Emily Hill, PA-C, president of Hill & Associates, a physician reimbursement and coding firm in Wilmington, N.C., spells out some of the rules for reimbursement of assistants at surgery, as outlined in the Medicare Carriers Manual.

Payment is made for an assistant at surgery when one or more of the following conditions are met:

1. The medical necessity for an assistant has been
demonstrated;
2. The surgery requires an assistant in more than 5
percent of the cases nationally; and/or
3. The assistance at surgery is performed in a hospital where no approved teaching program has been
established.

Per Medicares rules, when billing for an assistant at surgery, the primary surgeon reports the CPT code for the surgery without a modifier, and the assistant surgeon reports the code for the surgical procedure with modifier
-80 (assistant surgeon) to indicate that he or she was an assistant surgeon. When the surgical assistant is a non-physician practitioner such as a PA the -AS modifier is used instead.

Nancy Hughes, vice president of communications and information services for the American Association of Physician Assistants (AAPA), a national professional society representing PAs, clarifies some of the restrictions on PAs in teaching hospitals. In general, she says, payment is not made for first assisting when the service is provided in a teaching hospital that has a training program related to the particular surgical procedure and a qualified resident is available. But if the teaching hospital has no qualified resident available or if the primary surgeon has an across-the-board policy of not using residents, Medicare will cover the services of a PA first assistant.

Credentials for PAs

Hills explanation of Medicare benefits raises the issue of credentialing for PAs. Medicare requires that PAs bill under their own provider identification number (PIN). This means a PA billing for his or her assistance in a 27558 (open treatment of knee dislocation, with or without internal or external fixation; with primary ligamentous repair, with augmentation/reconstruction) would bill the code using his or her own provider number and the -AS modifier.

Most commercial carriers will not accredit PAs, and therefore the services of the PA have to be billed under either the physicians or the practices provider number, using either the -AS or the -80 modifier, depending on carrier preference.

What Fees to Expect

According to the AAPA, there are set percentages for which practices can anticipate being reimbursed for their PAs in surgery. Hughes explains some of the rules.

Coverage for PAs who are first assisting at surgery is provided at 85 percent of the physicians first-assisting fee, she says. Medicare will reimburse a physician who first assists at the rate of 16 percent of the primary surgeons fee. But PA first assists are covered at 85 percent of 16 percent (or 13.6 percent of the primary surgeons fee).

Private insurers rates will vary from this percentage by a point or two in either direction, up to approximately 20 percent. Hughes adds that in all cases, reimbursement for services provided by a PA is made to the practice, not the PA, even when using the PAs provider number. All billing is handled by the practice, not the individual PA. For practices like McGregors and Guerras where the PAs are full-time staff members, the practice bills for the PAs assistance along with the bill for surgery. Because the PA is a salaried staff member, there is no additional compensation, regardless of whether the PA assists in two or 20 surgeries per week.

The American College of Surgeons (ACS) publishes a helpful reference guide, Physicians as Assistants at Surgery. The guide lists every CPT 2000 surgical code, and whether a first assistant is required almost always, some of the time or almost never. Although the guide refers to the use of physicians and not PAs as first assistants, it is still helpful in justifying the use of a first assistant in surgery. The guide can be downloaded at www.facs.org/about_college/acsdept/socio_dept /se_pubs/sepubs.html or ordered from ACS by calling (312) 202-5150.

When billing Medicare for procedures the guide lists as requiring a first assistant at surgery some of the time, such as 29880 (arthroscopy, knee, surgical; with meniscectomy [medial AND lateral, including any meniscal shaving]), Guerra says his office discloses to the patient that Medicare may not reimburse for the PA who is necessary for the procedure. We have our patients sign a form provided by Medicare, says Guerra. That is sent with the PAs claim. The claim is billed with a -GA modifier (waiver of liability statement on file) in addition to the -AS modifier showing that the patient has been advised that the service may not be covered and that the patient accepts responsibility for the charge.

Hughes says that Medicare covers the first assist fees for most major surgical procedures, but has a list of approximately 1,900 CPT codes for which a first assistant at surgery will not be reimbursed. These code restrictions apply to both PAs and physicians, says Hughes. They include less-complex orthopedic procedures such as most types of closed treatment of fractures. A list of the affected CPT codes is available from local Medicare carriers.

Hughes says that most private carriers will reimburse for the services of a PA as a first assistant, but some will reimburse only when the first assistant is a physician. Coverage guidelines vary so its important to contact the payer for details on their specific policies, she says.

According to Hughes, most private carriers will reimburse for the services of a PA as a first assistant, but some will reimburse only when the first assistant is a physician. Coverage guidelines vary, she says, so its important to contact the payer for details on their specific policies.