Wiki Billing for Physician Assistant service under Supervising Dr

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katy1

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We are a GI specialist clinic. I have a question regarding a Physician Assistant seeing patients and billing under the supervising Doctor. Do commercial payers allow Supervising MD being the rendering provider instead of P.A who sees the patients if supervising Doctor is co signing the Physician assistants notes? I’m not referring to incident to billing. The Physician Assistant would not be listed in the claim at all. Since we bill as a group. So 24 j on 1500 claim from would have the supervising Dr listed. We are trying to avoid the 15% cut from some payers if it is possible and allowed by the insurance. I tried calling around some of the payer claims and provider relations but all they say is we can’t tell you how to bill?
 
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You are describing incident-to billing and then saying it's not incident-to. If the services were not incident-to, then they must be billed under the PA for reduced payment.
 
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You have to be careful with this. In order to bill "incident to" the physician must evaluate the patient first and the PA needs to follow that plan of care during any follow up visits. If the PA is working on their own then you will need to be billing under the PA and take the hit.
 
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katy1 said:
So this would only be allowed under incident to and basically if the payer allows it correct. What about through split shared expenses. How does this work?
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They have to both see the patient on the same day for any split/share to apply, and it only applies to established patients.

“A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer.”

Signing someone else's notes does not factor into it.
 
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I am trying to explain this to the physician's and that is the response I was expecting. Is there something you can refer me to that documents what could happen if they insist to bill the claims under the supervising physician rather than the P.A. who see's the patient.
 
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katy1 said:
I am trying to explain this to the physician's and that is the response I was expecting. Is there something you can refer me to that documents what could happen if they insist to bill the claims under the supervising physician rather than the P.A. who see's the patient.
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Well, you could google "penalties for medicare fraud" and see what comes up.

Are you sure they aren't doing incident-to work? The MD just has to see the patient for any new problem and then the PA can follow the treatment plan.
 
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At the hospital they will be seeing the initial consults and P.A. will see the follow ups but not in the office the P.A. is seeing the patient in the office. I will advised them it is only allowed when doing incident to billing and they must do the initial consult. Does incident to billing apply to hospital billing for the professional services?
 
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katy1 said:
At the hospital they will be seeing the initial consults and P.A. will see the follow ups but not in the office the P.A. is seeing the patient in the office. I will advised them it is only allowed when doing incident to billing and they must do the initial consult. Does incident to billing apply to hospital billing for the professional services?
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You said you were a clinic, so that's how all of the answers were given, as if this was all in a clinic.

There is no incident-to in the hospital.

It doesn't matter where the MD sees the patient first, as long as they evaluate the problem and make a treatment plan. Then the PA can see the patient to follow the treatment plan in the office.

If the patient starts in the clinic and not in the hospital, then either the MD sees the patient first or they bill under the PA, if the PA sees the patient first.
 
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Yes we are a GI clinic but they also round at the hospital. So when they are rounding if I understood you correctly incident to billing wouldn’t apply if P. A does the follow up in the hospital when the supervising Dr did the initial hospital consult? Thanks so much for answering all these questions.
 
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katy1 said:
Yes we are a GI clinic but they also round at the hospital. So when they are rounding if I understood you correctly incident to billing wouldn’t apply if P. A does the follow up in the hospital when the supervising Dr did the initial hospital consult? Thanks so much for answering all these questions.
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If the PA is rounding at the hospital, and the MD did NOT see the patient the same day, then you must bill under the PA. There is no incident-to in the hospital, only split/shared visits, and contrary to popular belief, merely signing off on a PA's notes does NOT constitute a shared visit. The MD must see the patient and document a service that they personally performed for it to be shared.

In the office setting, as long as the PA is not treating a new problem, AND the MD has already seen the patient and formulated a treatment plan, you can bill incident-to for the PA under the MD, as long as the MD is available if the PA needs them (and depending on where your office is, it may be okay if the doctor is at the hospital, and it may not be okay).
 
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Does the PA and Physician have to be in the same group for billing for PA who assisted the Surgeon. In the hospital i work for , we have Physicians that are in our group and some outside our group perform surgeries. Now to bill for PA's who assisted the physician from our group, i would add AS mod , but the question is Can i bill for PA's who assisted Physicians that are not from our group? Please advise . Thank you.
 
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OGGPPL said:
Does the PA and Physician have to be in the same group for billing for PA who assisted the Surgeon. In the hospital i work for , we have Physicians that are in our group and some outside our group perform surgeries. Now to bill for PA's who assisted the physician from our group, i would add AS mod , but the question is Can i bill for PA's who assisted Physicians that are not from our group? Please advise . Thank you.
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You cannot bill for the work or providers or staff who are not your group's employees or contract workers. The PA's employer will need to bill for their work as an assistant.

You also cannot bill PA services under a supervising physician when those services take place in a facility - 'incident to' billing is not allowed in a hospital.
 
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So again just to clear my doubts i have an Orthopedic surgeon who is not our doctor, performing surgery at our hospital assisted by our PA, and now to bill for PA we cannot use this Surgeon as he is not a part of our group. correct
Even though PA is from our group our hospital, only the primary surgeon is an outside doctor. And i am only talking bout surgeries here so does the "incident to " rule apply here.
 
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OGGPPL said:
So again just to clear my doubts i have an Orthopedic surgeon who is not our doctor, performing surgery at our hospital assisted by our PA, and now to bill for PA we cannot use this Surgeon as he is not a part of our group. correct
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Your wording here is making this very confusing. You are saying you 'have' a surgeon, but then you are saying the surgeon is not your doctor? And what do you mean by 'use this surgeon' to bill for your PA?

Let me put it this way: if your PA (meaning PA employed by the group for which you are billing), is working in the hospital and is being paid by your group for that work in the hospital, then you will bill those services under the credentials of the PA. It doesn't matter who the surgeon is, you'll still bill your PAs work the same way. But you cannot bill any of those services as 'incident to' any physician because billing a PA's work under the credentials of a physician requires that that service be performed in the office of the group that employs then and under the supervision of a physician from that group. But you can still bill the PA's services outside of that situation, just not using a physician's credentials. Hope that helps make it a little easier to understand.
 
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Got it. Sorry for the confusing language. So I am billing for a PA (from my group) who assisted a provider (not from group) under his own credentials. If this PA is not credentialed which he is not, I cannot bill this PA under this Surgeon as he is not from our group
 
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OGGPPL said:
Got it. Sorry for the confusing language. So I am billing for a PA (from my group) who assisted a provider (not from group) under his own credentials. If this PA is not credentialed which he is not, I cannot bill this PA under this Surgeon as he is not from our group
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Yes, modifier AS if the PA assisted at surgery.

You will need to credential your PA with your payers. As I mentioned above, you cannot bill this under a physician, even if it is your own physician, because 'incident to' billing is not permitted in a hospital setting. The only exception I know of for this is if your payer does not allow you to credential the PA, in which case they should give you guidance on how they want you to bill that provider's services.

Your practice really should not be having the PA work in the hospital if they are not credentialed to bill on their own. If payer audited you and discovered that you were billing claims for hospital services under a physician who did not actually personally perform those services, they could recoup all of those payments and the practice could potentially face severe penalties. You really need to have a compliance specialist evaluate this situation.
 
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got ot
thomas7331 said:
Yes, modifier AS if the PA assisted at surgery.

You will need to credential your PA with your payers. As I mentioned above, you cannot bill this under a physician, even if it is your own physician, because 'incident to' billing is not permitted in a hospital setting. The only exception I know of for this is if your payer does not allow you to credential the PA, in which case they should give you guidance on how they want you to bill that provider's services.

Your practice really should not be having the PA work in the hospital if they are not credentialed to bill on their own. If payer audited you and discovered that you were billing claims for hospital services under a physician who did not actually personally perform those services, they could recoup all of those payments and the practice could potentially face severe penalties. You really need to have a compliance specialist evaluate this situation.
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This is exactly what I was confused of . Thank you . Its all clear now. thank you much and sorry for confusion. I just wanted to be clear on this. thank you
 
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thomas7331 said:
Your wording here is making this very confusing. You are saying you 'have' a surgeon, but then you are saying the surgeon is not your doctor? And what do you mean by 'use this surgeon' to bill for your PA?

Let me put it this way: if your PA (meaning PA employed by the group for which you are billing), is working in the hospital and is being paid by your group for that work in the hospital, then you will bill those services under the credentials of the PA. It doesn't matter who the surgeon is, you'll still bill your PAs work the same way. But you cannot bill any of those services as 'incident to' any physician because billing a PA's work under the credentials of a physician requires that that service be performed in the office of the group that employs then and under the supervision of a physician from that group. But you can still bill the PA's services outside of that situation, just not using a physician's credentials. Hope that helps make it a little easier to understand.
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Hello Thomas,
I am trying to fix few PA billing issues and would like to confirm my understanding from our above discussion that " Although PA and Surgeon are from same group in a hospital setting, & PA assisted this Surgeon with a surgery, then I am to bill this PA under his/her own credentials . I cannot bill this PA under the Surgeon/ Supervising provider as it would be considered to as "incident -to billing" which is not permitted in a hospital setting. As stated here,
because billing a PA's work under the credentials of a physician requires that that service be performed in the office of the group that employs then and under the supervision of a physician from that group
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Surgeon was present in the OP room and PA assisted him and they are both in the same group. Will this be considered as an Incident - to in a hospital setting,

So when am I to use modifier "AS" for PA's assistance in the surgery. Please advise.
 
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my confusion still is HOW and IF I CAN bill PA's who assisted Surgeons during the surgeries in a hospital setting. BOTH PA & SURGEON belong to same group.
Can I bill them or is considered as incident- to?
If I can bill them then should I bill PA under his/her own credentials ?
OR bill with AS modifier with Supervising surgeon - If I do so is this considered as incident-to billing or not?
Please help me understand this one more time. Thank you
 
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OGGPPL said:
my confusion still is HOW and IF I CAN bill PA's who assisted Surgeons during the surgeries in a hospital setting. BOTH PA & SURGEON belong to same group.
Can I bill them or is considered as incident- to?
If I can bill them then should I bill PA under his/her own credentials ?
OR bill with AS modifier with Supervising surgeon - If I do so is this considered as incident-to billing or not?
Please help me understand this one more time. Thank you
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OK, for ALL professional services performed in the hospital, you bill each service under the provider who performed that service. So the physician acting as the surgeon will bill the surgery under their own credentials and the PA who assisted will bill their services, with the AS modifier, under the PA's credentials. There is no 'incident to' billing allowed for services performed in a hospital, so you can never use the physician's credentials to bill for the PA's work that was done in a hospital. (The only exception is a split/shared visit where both physician and PA perform a portion of an E/M service for that patient in the hospital on the same date, but that is a different thing and is not 'incident to').

In a physician's private office the physician may bill, under his or her own credentials, the services performed by his or her own group's employees when those services meet the definition of 'incident to', which means primarily that those services are performed to carry out the physician's plan of care for the patient, and which are performed under the direct supervision of the physician (i.e. the physician is in the office and available to assist if needed when the services are performed). So when a PA, who is employed by the physician (or group) is fulfilling this function in the office and is not treating any new problems or making any independent decisions that alter the plan of care that the physician has ordered for the patient, then their services may be billed using the physician's credentials. But if any of those requirements aren't met, then the PA's work needs to be billed under their own credentials.

Does that help explain it better?
 
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thomas7331 said:
OK, for ALL professional services performed in the hospital, you bill each service under the provider who performed that service. So the physician acting as the surgeon will bill the surgery under their own credentials and the PA who assisted will bill their services, with the AS modifier, under the PA's credentials. There is no 'incident to' billing allowed for services performed in a hospital, so you can never use the physician's credentials to bill for the PA's work that was done in a hospital. (The only exception is a split/shared visit where both physician and PA perform a portion of an E/M service for that patient in the hospital on the same date, but that is a different thing and is not 'incident to').

In a physician's private office the physician may bill, under his or her own credentials, the services performed by his or her own group's employees when those services meet the definition of 'incident to', which means primarily that those services are performed to carry out the physician's plan of care for the patient, and which are performed under the direct supervision of the physician (i.e. the physician is in the office and available to assist if needed when the services are performed). So when a PA, who is employed by the physician (or group) is fulfilling this function in the office and is not treating any new problems or making any independent decisions that alter the plan of care that the physician has ordered for the patient, then their services may be billed using the physician's credentials. But if any of those requirements aren't met, then the PA's work needs to be billed under their own credentials.

Does that help explain it better?
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Yes, this clears my confusion from roots. I am only working surgeries and so the surgeries assisted by PA's in the same group as the surgeon, I am to bill the PA's assistance under his/her credentials with AS Modifier even though the Surgeon is from the same group as incident- to billing is not allowed in hospital. Correct?
 
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OGGPPL said:
Yes, this clears my confusion from roots. I am only working surgeries and so the surgeries assisted by PA's in the same group as the surgeon, I am to bill the PA's assistance under his/her credentials with AS Modifier even though the Surgeon is from the same group as incident- to billing is not allowed in hospital. Correct?
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Incident to cannot take place at a facility such as a hospital. For surgeries, if the PA assists you bill with the -AS modifier.
 
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thomas7331 said:
OK, for ALL professional services performed in the hospital, you bill each service under the provider who performed that service. So the physician acting as the surgeon will bill the surgery under their own credentials and the PA who assisted will bill their services, with the AS modifier, under the PA's credentials. There is no 'incident to' billing allowed for services performed in a hospital, so you can never use the physician's credentials to bill for the PA's work that was done in a hospital. (The only exception is a split/shared visit where both physician and PA perform a portion of an E/M service for that patient in the hospital on the same date, but that is a different thing and is not 'incident to').

In a physician's private office the physician may bill, under his or her own credentials, the services performed by his or her own group's employees when those services meet the definition of 'incident to', which means primarily that those services are performed to carry out the physician's plan of care for the patient, and which are performed under the direct supervision of the physician (i.e. the physician is in the office and available to assist if needed when the services are performed). So when a PA, who is employed by the physician (or group) is fulfilling this function in the office and is not treating any new problems or making any independent decisions that alter the plan of care that the physician has ordered for the patient, then their services may be billed using the physician's credentials. But if any of those requirements aren't met, then the PA's work needs to be billed under their own credentials.

Does that help explain it better?
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Thank you for detailed explanation. This is very helpful.
 
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Hi Thomas, Thank you for the clarification in billing "incident to", If the PA is seeing an established patient following the MD"s treatment plan, does the PA have to send the chart to the MD to sign off on the note?
 
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FPacheco said:
Hi Thomas, Thank you for the clarification in billing "incident to", If the PA is seeing an established patient following the MD"s treatment plan, does the PA have to send the chart to the MD to sign off on the note?
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Medicare's incident-to guidelines do not require MD co-signature on the chart.
Some practices or health systems have it as an internal guideline, but it is not required by Medicare. I manage a few practices and for most of them, incident-to is hardly ever met so we don't even bother checking every chart for the 1 per month that might be incident-to. One of the practices meets incident-to very frequently. For that practice, as a logistics issue, we have the onsite physician co-sign so we know which physician was onsite at that specific location (they have several locations). This way, if the coder determines it meets all other incident-to requirements, and the carrier follows incident-to, we know which MD to put on the claim.
 
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Also, aside from the billing and coding implications above, there may be state supervision requirements for PAs and NPs separate from this which require co-signature. And, as Christine said, some groups may have internal rules to follow.
 
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there are several levels of guidelines you need to wade through according to each setting. there are state scope of practice guidelines, payer guidelines, practice guidelines, & health system/hosp guidelines that all APPs are subject to. if they can make it through all that then you have to make the distinction between hosp based billing (shared/split visits) & provider based out pt billing (incident to). although the concepts are the same there are different guidelines & variations for each. MD involvement differs depending on the setting so be sure you know which guidelines apply to you. i work for a hosp based outpt clinic- confusing enough by itself!!
 
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Incident to, is this ONLY for the office setting then? The provider I bill for is Primary Care and visits his patients in assisted living. NOT skilled nursing.
A lot of our patients reside in AL and we bill the Home Visit codes in POS 13. I'm baffled on the incident to. Our NP goes to the AL with him and follows up on his established visits while he is available and seeing new patient issues. I was told incident-to is only in an office setting.
 
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