Wiki Family Practice/ Billing for a Physician Assistant

[acopeland75@live.com]

I hope someone can help me! My office just brought on a Physician Assistant which I am currently credentialing, and there is a ton of confusion in the billing department in regards to properly billing under her own NPI, and understanding the incident to billing. Any help would be appreciated

 

[Pathos]

Once fully credentialed, most payers will accept a PA's NPI for billing. However, you can bill "Incident-To" for most payers (check with your payers policy, as not all follow CMS guidelines).

Here's some readings:

Noridian (my MAC)

Palmetto (MAC)

Novitas (MAC)

CGS Medicare (MAC)

AAFP article on Incident To rules

Hope this is helpful!

 

[shughes6560]

Harvard pilgrim incident-to rules

Hi,
I live in MA and Harvard Pilgrim will only credential a PA as a PCP. They updated their policy with a new modifier to start using as of 1/1/19 and it states you would use that when you are billing under a supervising provider. I can't find anywhere that states what their actual incident-to rules are. This is what they show. But below I have also pasted their policy review dates and they show 11/15/10 updated CMS standard methodology replaced with HPHC standard methodology but I can't find anything that states what that is??
Provider Billing Guidelines and Documentation
• When Harvard Pilgrim does not contract directly with the non-physician practitioner submit claims by appending
modifier SA and using the supervising physician’s name in box 31 of the paper CMS-1500, and supervising physician’s National Provider Identifier (NPI) in box 24j of the CMS-1500 form for paper submitters. For electronic
submitters send supervising physician’s National Provider Identifier (NPI) in segment NM109 with 82 qualifier in
NM108 of loop 2310B of the electronic 837P, version 5010. As of January 01, 2019 modifier SA is required.
• When Harvard Pilgrim contracts directly with the non-physician practitioner submit claims using the non-physician
practitioner’s name and National Provider Identifier (NPI) without modifier SA.
• Bill non-physician assistant surgeon services with an AS modifier in the first modifier field; this applies even if the claim
is submitted under the contracted supervising physician’s National Provider Identifier (NPI).
Modifier Description Comments
AS Physician billing for non-physician practitioner for assistant at surgery
Reimbursed at 16% of the applicable allowable rate
SA Physician billing for non-physician practitioner No impact on reimbursement

Publication History
07/01/03 original documentation
04/01/05 annual review; removed incident-to and independent services requirements
01/31/06 annual review; MA NP contract exception language added
04/30/07 annual review; minor edits for clarity
04/30/08 annual review; policy title change; edits for clarity
11/10/08 added MA NP as PCP–effective January 1, 2009
01/31/09 updated NPI info for clarity
03/15/09 annual review, added clinical midwives, updates to assistant surgery modifiers
04/15/10 annual review; no changes
11/15/10 policy update, CMS standard methodology replaced with Harvard Pilgrim standard methodology

 

[betsytaft]

Harvard pilgrim incident-to rules

Hi,
I live in MA and Harvard Pilgrim will only credential a PA as a PCP. They updated their policy with a new modifier to start using as of 1/1/19 and it states you would use that when you are billing under a supervising provider. I can't find anywhere that states what their actual incident-to rules are. This is what they show. But below I have also pasted their policy review dates and they show 11/15/10 updated CMS standard methodology replaced with HPHC standard methodology but I can't find anything that states what that is??
Provider Billing Guidelines and Documentation
• When Harvard Pilgrim does not contract directly with the non-physician practitioner submit claims by appending
modifier SA and using the supervising physician’s name in box 31 of the paper CMS-1500, and supervising physician’s National Provider Identifier (NPI) in box 24j of the CMS-1500 form for paper submitters. For electronic
submitters send supervising physician’s National Provider Identifier (NPI) in segment NM109 with 82 qualifier in
NM108 of loop 2310B of the electronic 837P, version 5010. As of January 01, 2019 modifier SA is required.
• When Harvard Pilgrim contracts directly with the non-physician practitioner submit claims using the non-physician
practitioner’s name and National Provider Identifier (NPI) without modifier SA.
• Bill non-physician assistant surgeon services with an AS modifier in the first modifier field; this applies even if the claim
is submitted under the contracted supervising physician’s National Provider Identifier (NPI).
Modifier Description Comments
AS Physician billing for non-physician practitioner for assistant at surgery
Reimbursed at 16% of the applicable allowable rate
SA Physician billing for non-physician practitioner No impact on reimbursement

Publication History
07/01/03 original documentation
04/01/05 annual review; removed incident-to and independent services requirements
01/31/06 annual review; MA NP contract exception language added
04/30/07 annual review; minor edits for clarity
04/30/08 annual review; policy title change; edits for clarity
11/10/08 added MA NP as PCP–effective January 1, 2009
01/31/09 updated NPI info for clarity
03/15/09 annual review, added clinical midwives, updates to assistant surgery modifiers
04/15/10 annual review; no changes
11/15/10 policy update, CMS standard methodology replaced with Harvard Pilgrim standard methodology

Just wondering if you found any additional information on your question.