Billing for a Physician Assistant

kjoseph

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Hi,
I bill for a family practice who has taken on a Physician Assistant. I am not sure how to bill for him. If I use her NPI that does not seem right and if I use his - he is not a member of any insurance companies yet so those claims will be not be processed correctly...I looked on the Medicare website but really did not get it...any help?

thanks
Kathy
 
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Milwaukee WI
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Credentialing

You will need to get the PA credentialed with the payers. How you bill will then depend on the services provided and whether a particular payer follows the "incident to" rules.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

aaron.lucas

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would you use the NPI of the PA though? I would think so, because the only situation I can think of that you would use someone else's NPI would be Locum Tenens. and if they wait to bill until after the PA is credentialed, is that retro-active or does it only apply to DOS after the credential date? kinda curious about that for myself too.
 

btadlock1

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Lubbock, TX
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Hi,
I bill for a family practice who has taken on a Physician Assistant. I am not sure how to bill for him. If I use her NPI that does not seem right and if I use his - he is not a member of any insurance companies yet so those claims will be not be processed correctly...I looked on the Medicare website but really did not get it...any help?

thanks
Kathy
The rules vary by payer, but here's a short run-down (please check with your payers to be sure):
Medicare - you should contract the PA under his own rendering NPI (eg, the one that goes in 24J) - since he's part of a group, he will likely have the same NPI as the MD in 33a (billing NPI). You can bill the PA as the MD (using the MD's rendering NPI in 24J) under a few circumstances (called "incident-to") - it can't be for new patients, or acute conditions - basically, the only time you can bill the PA as the MD to Medicare, is when the MD has already initiated a treatment plan, and the patient is seeing the PA for a follow-up visit. The MD must also be physically present in the office suite at the TOS.
Medicaid: Varies by state...I can't help you without knowing where you're at.
Commercial: Many payers will allow you to bill under an MD's name, following the same type of rules as Incident-to; since the PA is an employee of the MD, it's allowed - but you'll need to check on an individual payer basis, to ensure that you're not violating any of your contracts.

The reason you'd bill under the MD's rendering NPI (versus the PA's), is that PA's are typically paid at a reduced rate (anywhere from 80%-90% of the MD fee schedule, depending on the payer); So even when you're allowed to bill under the MD's #'s (because you haven't contracted the PA yet, usually), you still have to do something to flag the claim, so that they know to apply the discount, in most cases. (Most want you to add a modifier, like the SA modifier, to your charges). Because of all of the hurdles involved in billing PA's under the MD's rendering info, it's usually better to bill under the PA's own #'s, when you can - that means that you'll need to make sure that the PA's contracted with the payers. If you need help finding the rules for specific payers, let me know what state, and I'll send you some links. Hope that helps! ;)
 

HOFPG

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physician assistant - incident to

can someone please advise how a physician assistant should be listed on the cms-1500 for Medicare, when incident to guidelines have been met
 

bkraft

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The rules vary by payer, but here's a short run-down (please check with your payers to be sure):
Medicare - you should contract the PA under his own rendering NPI (eg, the one that goes in 24J) - since he's part of a group, he will likely have the same NPI as the MD in 33a (billing NPI). You can bill the PA as the MD (using the MD's rendering NPI in 24J) under a few circumstances (called "incident-to") - it can't be for new patients, or acute conditions - basically, the only time you can bill the PA as the MD to Medicare, is when the MD has already initiated a treatment plan, and the patient is seeing the PA for a follow-up visit. The MD must also be physically present in the office suite at the TOS.
Medicaid: Varies by state...I can't help you without knowing where you're at.
Commercial: Many payers will allow you to bill under an MD's name, following the same type of rules as Incident-to; since the PA is an employee of the MD, it's allowed - but you'll need to check on an individual payer basis, to ensure that you're not violating any of your contracts.

The reason you'd bill under the MD's rendering NPI (versus the PA's), is that PA's are typically paid at a reduced rate (anywhere from 80%-90% of the MD fee schedule, depending on the payer); So even when you're allowed to bill under the MD's #'s (because you haven't contracted the PA yet, usually), you still have to do something to flag the claim, so that they know to apply the discount, in most cases. (Most want you to add a modifier, like the SA modifier, to your charges). Because of all of the hurdles involved in billing PA's under the MD's rendering info, it's usually better to bill under the PA's own #'s, when you can - that means that you'll need to make sure that the PA's contracted with the payers. If you need help finding the rules for specific payers, let me know what state, and I'll send you some links. Hope that helps! ;)
Can you please send me links for these payers for Arizona:
BCBS
Aetna
Humana Med Adv
Humana Commercial
P3 Health Partners of AZ
AARP Medicare Complete
GEHA

I'm having no luck searching the payer portals. Thank you for any help you can provide.
 

coloradopa

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Georgia
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btadlock1 is correct. I'll add a little nuance. For Medicare you bill under the PAs NPI and are reimbursed at 85% of the physicians rate. There are circumstances where you can use incident to and shared billing to bill under physicians NPI, however there are significant rules for this and for the most part it only applies to Medicare.

Medicaid is state by state but most bill under the PAs NPI. Some may or may not allow incident to.

Private insurers - the vast majority don't credential PAs and you bill under the physicians NPI at 100%. For those that are credentialed follow their guidelines such as:

Here is the AAPA statement on reimbursement

In addition if you have specific PA billing questions AAPA has reimbursement specialists that are usually very helpful.
 
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