Answer PA e/m coding for Hospital visits?

cliff.chen89

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If the PT has a hospital visit/consult where they are seen by the PA. The PA is employed by the Dr and works for the Dr's group/company. The note will have the HPI, the lab results, and then the assessment and plan. But, the MD is not clearly documenting that they saw the PT face-to-face. For example:

Assessment:
PT with L distal clavicle fracture

Plan:
1. Care per primary team
2. NWB LUE, sling for comfort
3. Pain control
4. Will proceed with conservative management of left distal clavicle fracture
5. Disposition: stable from Ortho standpoint, f/u with Ortho in 2 weeks

Attestation signed by Dr. ABC
Patient who sustained minimally displaced left lateral clavicle fracture after fall on beach. I reviewed patient's medical chart and imaging prior to this consultation. Care plan for treatment established in conjunction with PA as described above. Closed treatment of clavicle fracture recommended with outpatient followup.

Physician Assistant XYZ, PA at (Date & Time of signature)
Cosigned by: Dr. ABC, MD at (Date & Time of signature)



My understanding is that as per this article, unless my doctor specifically writes that they saw the PT face-to-face (e.g. I personally saw the PT on today's date) that I may NOT bill the visit under the Dr's name and instead I have to bill this under the PA's name.

1) In the above example, am I correct in telling my doctor that this cannot be billed under his name, that it can only be billed under the PA's name?

2) If closed treatment is performed as per above example, can I bill the closed treatment under the PA's name even without billing the Dr as the primary/supervising MD? Since in my experience the insurance will deny the PA's surgery bill/services without also submitting the primary/supervising MD bill?

3) Lastly, does the E/M code (99222) and Closed treatment (23500) have to be billed with any modifiers? Do I bill under the PA's name as:

99222-57
23500-RT

or do I add modifiers:

99222-57-SA
23500-AS-RT?

4) IIRC medicare does not recognize the SA modifiers, so if the insurance is medicare, is there another modifier I should use?

5) Even though this was an emergency and PT was first seen in the emergency room, but they were admitted to the hospital, should I code as 9922X or 9928X?
 

Birdie625

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Hi me again....im guessing the "note" example was just to emphasis the MDs attestation....

1) yes; This is a little over my head... There are certain rules re: split/shared visits (is this the same as Incident-to ?) - and I get lost re: such. I do want to add my thought in this particular instance, the provider would have had to have seen pt and assessed and formed a plan of action as this is a NEW patient or problem (at least a new problem) in order to bill his NPI.

2) bill under PA npi; they shouldn't deny...UNLESS this PA has some sort of credentialing issue w/type of Insurance. I know from my experience, HP ins will not credential PA's (in my location anyway); they have to have a supervising physician over-seeing them (in same office, floor, etc stuff). IF the Pt had HP (Harvard Pilgrim) Ins and the PA billed only under their NPI (because MD wasn't on floor, suite, etc stuff), the claim would be denied. We would adj as no supervising physician. We would NOT bill under the MD's name if they were not around.

3) 99222-57 // 23500-RT ---format is correct...but the 99222 is for IP POS only

3) Mod SA is unknown. The 23500-AS-RT would be ONLY if a PA assisted a surgeon....however, this particular scenario, it will deny as per CPT no assist at surgery is allowed.

4) I don't know what IIRC Medicare is and possibly they don't recognize SA as I don't think it exists?? I looked and couldn't find it (in CPT book)

5) it depends on "who" admitted pt. Also per that example, it seems OP f/up only (hence, no admission needed from their standpoint) Did a Hospitalist also see pt (d/t other comorbidities) and possibly they admitted? I honestly don't know or not if a PA can admit (write orders) for such.....IF let say in this case the PA could write orders, and they admitted, the e/m cpt would depend then again on if admitted to OBS or IP. They would combine all work they did in ER and with other admission work for their level. If they admitted to OBS it would be range 99218-99220; IP range 99221-99223. HOWEVER...if Hospitalist admitted, then your PA would bill a 9928x code...I have been told for my work that an ER provider cannot request 'consult' to anyone so no "consult" type CPT would be billed (...or a provider cannot code a 'consult' resulting from a request to see pt by an ER provider).

6) These are my thoughts and interpretations only...and things from my experience...I am by no means thoroughly trained or otherwise....Thanks...
 
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