PA billing E/M level based on time for counseling and coordination of care

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Can a physician assistant bill an established E/M level based on time for counseling and coordination of care?

Any help on this would be greatly appreciated.
M.Roberson
 

ljulien

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Yes, a PA can bill. PA's/NP's are qualified health care providers.
 

Jennifer Turner

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Local Chapter Officer
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Absolutely! It must be more than 50% of the encounter and also must be documented in the medical record along with a description of what was being counseled and/or activities to coordinate care. There is no current rule/guideline that will limit the PA from billing a time based services. The only distinction is that as with any other service the PA will be reimbursed at 85%.

Below is a link to a E/M manual from CMS. I refer to it often because it is very helpful. You may want to save it to your favorites, place it in a folder, or save it on your desktop. Beginning on pg. 36 are the rules for time base services.

https://www.cms.gov/Outreach-and-Ed.../Downloads/eval-mgmt-serv-guide-ICN006764.pdf

To be extra careful you may also check with your commercial carrier or MAC to see if their policy has any stipulations.
 
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Thank you for your feedback. I just want to be clear that you are saying "physician" can mean a non-physician provider because I thought CMS always referred to PAs and NPs as non-physician providers (NPP) or if stating a guideline that refered to both a physician and NPP they would state it as "providers".

In an article by our MAC, Palmetto, Dec. 28, 2016, E/M Weekly Tip: Counseling/Coordination Office Setting it states:

Counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided.
Patient is not present in the office:
Counseling/coordination of care with the patient’s family alone (i.e., patient is at home) is not a billable service.
Patient is present in the office:
If the family members/provider needs to perform counseling/coordination of care away from the patient they may leave the room and go to the hallway/private room. Time with the family may be included in the selection of the CPT code.

These guidelines state Face-to-Face time refers to the time with the physician only...it does not say with a provider or NPP. Doesn't CMS usually refer to PAs and NPs as NPP or non-physician providers in their guidelines?
 
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Thank you for your feedback. I just want to be clear that you are saying "physician" can mean a non-physician provider because I thought CMS always referred to PAs and NPs as non-physician providers (NPP) or if stating a guideline that refered to both a physician and NPP they would state it as "providers".

In an article by our MAC, Palmetto, Dec. 28, 2016, E/M Weekly Tip: Counseling/Coordination Office Setting it states:

Counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided.
Patient is not present in the office:
Counseling/coordination of care with the patient’s family alone (i.e., patient is at home) is not a billable service.
Patient is present in the office:
If the family members/provider needs to perform counseling/coordination of care away from the patient they may leave the room and go to the hallway/private room. Time with the family may be included in the selection of the CPT code.

These guidelines state Face-to-Face time refers to the time with the physician only...it does not say with a provider or NPP. Doesn't CMS usually refer to PAs and NPs as NPP or non-physician providers in their guidelines?
 

Jennifer Turner

Networker
Local Chapter Officer
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Indianapolis, IN
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Physicians or other qualified healthcare professional is an individual who is qualified by education, training, licensure/regulation, and facility privileging who performs a professional service within his or her SCOPE of practice and independently reports the professional service. "Staff" is persons who work under the supervision of a "physician or other qualified healthcare professional" who is allowed to perform or assist in the performance of a specific professional service, BUT does not individually report that professional service.

Furthermore, E/M services may also be reported by other qualified healthcare professionals who are authorized to perform such services within the scope of their practice. Please refer to pg. 4 & the coding note on pg 5 of your 2017 CPT book.

I think that the "staff" part is what you are getting hung up on.... PA's are not considered "staff" as they are Providers with their own NPI.
 
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My Director of Coding and Compliance says that CPT guidelines state that "other qualified healthcare professionals can bill based on time" but that CMS guidelines regarding billing E/M based on time states only "physicians" and does not state "or other qualified healthcare professionals" this meaning only physicians can bill based on time, but I have a PA that is disagreeing. However, in most cases CMS guidelines usually do state "physicians or other healthcare professionals" or "physicians and non-physician practitioners" if the billing guideline applies to the NPPs. I cannot find anything from CMS or our local MAC that specifically states that a PA can bill based on time. I have emailed our local MAC and waiting a response to clarify the guidelines.
 

Jennifer Turner

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Local Chapter Officer
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Indianapolis, IN
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Advise physicians to use CPT codes (level 1 of HCPCS) to code physician services, including evaluation and management services. Medicare will pay for E/M services for specific non-physician practitioners (i.e., nurse practitioner (NP), clinical nurse specialist (CNS) and certified nurse midwife (CNM)) whose Medicare benefit permits them to bill these services. A physician assistant (PA) may also provide a physician service, however, the physician collaboration and general supervision rules as well as all billing rules apply to all the above non-physician practitioners. The service provided must be medically necessary and the service must be within the scope of practice for a non-physician practitioner in the State in which he/she practices.

You may also refer to Pub. 100-4 Medicare Claims Processing.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r178cp.pdf

I have to go with the PA on this one as he/she is correct.
 
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