Wiki Physician Assistants billing

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Hi there, you should start with the state scope of practice for physician assistants. That controls the types of services they are legally allowed to perform, supervision requirements and so on. The AAPA (American Academy of Physician Associates) will have links to relevant state laws.
 
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jkyles@decisionhealth.com said:
Hi there, you should start with the state scope of practice for physician assistants. That controls the types of services they are legally allowed to perform, supervision requirements and so on. The AAPA (American Academy of Physician Associates) will have links to relevant state laws.
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Thank you for your response. I was not clear when I posed the question, what I'm looking for is the Medicare edits/list that show what cpt codes physicians assistants are allowed to bill for. I know there is a list per Medicare of codes that they say no assistant allowed/necessary to bill for this code. Again, any help would be great.
 
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I've never heard of such a list for physician assistants or other NPPs. Are you thinking of codes that allow a surgical assistant?
 
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It sounds like you are talking about assistant-at-surgery.

Assistant at Surgery Modifiers Fact Sheet

www.novitas-solutions.com www.novitas-solutions.com
The Medicare physician fee schedule (JH) (JL) status indicators for assistant at surgery services should be used to determine if the procedure is allowed with the assistance of a second surgeon.
Most coding software like Encoder also has this information when you look up codes.

If not talking about assistant at surgery you would need to start where jkyles suggested with state scope. There are some instances like with ultrasound guided procedures where it requires extra training and supervision for the NPP to bill for it. Also, there can be instances such as with X-Rays where a PA can't do general supervision of the TC component of an X-Ray. They could order it and do the professional component (26) but not the TC.
See the CMS Manual: 190 - Physician Assistant (PA) Services
B. Covered Services Coverage is limited to the services a PA is legally authorized to perform in accordance with State law (or State regulatory mechanism provided by State law).

This is from 2018 but you can see as a reference: https://www.ama-assn.org/sites/ama-...te-law-physician-assistant-scope-practice.pdf
 
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Also forgot to add, your PAs & NPs are really good advocates for themselves usually. Many of the NPPs I have worked with know the rules and can be your partner when it comes to understanding them. If your practice already has PAs employed they can be your partner in this process. They also may have access to some of the resources with the AAPA that is "member only" content.
 
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Can someone shed some light on this topic for me. I am a newly certified coder and I work at a fertility clinic. Our clinic has 1 REI, 3 NP's, and 2 PA's. I know our NP's can bill under their own NPI and don't require the supervision of a physician. But the question has been asked about the PA's. As of now the way we bill is the PA as the rendering provider and the MD as the supervising provider. The claim pulls with the supervising providers npi, and not the npi of the PA. From what I have been reading, the reimbursement for PA services is usually reduced from that of a MD. We are not contracted with CMS, so would those guidelines still apply? I know most insurance companies follow CMS guidelines. Is there a way that we can bill for PA services with a supervising physician but show that the PA performed the service. Are there only certain procedure that a PA has to be "supervised" for. Should we be using a modifier to represent the services were rendered by a PA? I've read so many different threads and articles, and now I feel like I've fallen into a wormhole and don't know what is right anymore!! HELP!!
 
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brookepoole1985@yahoo.com said:
Can someone shed some light on this topic for me. I am a newly certified coder and I work at a fertility clinic. Our clinic has 1 REI, 3 NP's, and 2 PA's. I know our NP's can bill under their own NPI and don't require the supervision of a physician. But the question has been asked about the PA's. As of now the way we bill is the PA as the rendering provider and the MD as the supervising provider. The claim pulls with the supervising providers npi, and not the npi of the PA. From what I have been reading, the reimbursement for PA services is usually reduced from that of a MD. We are not contracted with CMS, so would those guidelines still apply? I know most insurance companies follow CMS guidelines. Is there a way that we can bill for PA services with a supervising physician but show that the PA performed the service. Are there only certain procedure that a PA has to be "supervised" for. Should we be using a modifier to represent the services were rendered by a PA? I've read so many different threads and articles, and now I feel like I've fallen into a wormhole and don't know what is right anymore!! HELP!!
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I think you may be confusing 2 concepts here. There are BILLING requirements, and legal SUPERVISION requirements.

The billing requirements are the same for your NPs and PAs. IF the service meets incident-to AND IF the carrier follows incident-to billing, then services rendered by NPs and PAs may be billed under the physician. Some of those incident-to requirements include - established patient, established plan of care, physician in the suite and immediately available. If the incident-to requirements are not met, then the services rendered by your NPs and/or PAs cannot be billed as incident-to. If the carrier does not follow incident-to billing (I think all mine do), you must follow the guidance/policy of the carrier, which is usually to bill under the NP/PA. Those services are typically paid at 85% of the physician fee schedule. Whether or not incident-to bills require a modifier is up to the carrier. I think it's United Healthcare that requires -SA on those claims.

The legal supervision requirements vary state to state and differ for NPs and PAs. A coding forum is not the best place to answer scope of practice type of questions. Your state education department may be a good resource. National organizations such as AAPA, AANP or your state's NP/PA organizations can also be helpful resources.

It also sounds like you also may be having an issue with how the billing portion of your EHR is set up. If you are trying to bill under a PA, but the claim is only showing the MD info, you should find out from your vendor how to properly configure that.

I hope this helps you sort out at least some of it. Good luck!
 
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