Wiki Same day


Yakima, WA
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My mind is drawing a blank.

One of our PA’s sees a new patient and the same day they are seen by Dr for an excision. I am thinking both providers won't get paid. Can I put a modifier on the PA charges? Same Tax ID, but individual NPI #'s.

You didn't say if the PA's visit and the provider performing the excision are related.

A PA can see a new patient on their own. However, this would not fall under incident-to because the PA can only see established patients with established problems/plan of care for incident-to. For this non-incident-to E/M the PA you could bill the E/M under the NPI number of the PA in box 24J of the claim. The PA's services would be paid at 85% of the regular physician fee schedule.

If the excision was performed by the MD/DO and was unrelated to the E/M visit, the MD or DO would bill for their services (excision) and would insert their NPI number on box 24J.

If however, the PA did the E/M and this lead to the decision to perform the excision (i.e., they are related), then you cannot bill for the E/M separately. The MD or DO should still need to examine the patient and perform any E/M related to the procedure.

The excision is a minor surgical procedure (10 postop days) and any E/M related to it is included in the reimbursement for the surgical procedure. This is true for both new and established patients.

The fact that two providers are involved (PA and the MD/DO) for this patient means they are considered part of a group. Service performed by members of the group with the same specialty (Dermatology specialty code = 07) are treated as of they were performed by a single provider for coding and billing purposes.
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