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Wiki Surg Reimb Brkout for both Doc & PA/NP Assting

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schweitzerm

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Good evening! I'm very new to all of this, especially Medicare rules and regs, so I am very grateful for any help. My question - if a surgeon has an NP or PA as a surgical assistant, how is reimbursement broken out under Medicare? My meager understanding is that the PA/NP would receive 16% of the surgeon's allowable reimbursement. Does this mean that the doc gets the balance of the allowable? This question may sound stupid, but I haven't been able to find any sort of language on CMS to show a break out. Perhaps, I don't know enough about Medicare "speak" to understand what they mean. Any help would be most appreciated.
 
I believe that the payment is not carved out of the surgeon's fee, but that the assistant gets 16% of the allowable for the surgery - if they are a PA. An MD or DO would get 25%, as I understand it. If I am wrong, hopefully someone else will join in the conversation and correct me. :-)
 
Thank you, Elizabeth, for your prompt response. If Medicare doesn't carve out PA/NP reimbursements from total Medicare reimbursable from the doc, are there any other payers/carriers that do?

Thanks again for your time and expertise :)
 
I agree with the above response. We bill for PA/NP's pretty much daily, to a variety of payers, and I'm not aware of any of them "carving out" part of the primary surgeons' fee to pay the assist.

Hope this helps! :)
 
schweitzerm said:
Good evening! I'm very new to all of this, especially Medicare rules and regs, so I am very grateful for any help. My question - if a surgeon has an NP or PA as a surgical assistant, how is reimbursement broken out under Medicare? My meager understanding is that the PA/NP would receive 16% of the surgeon's allowable reimbursement. Does this mean that the doc gets the balance of the allowable? This question may sound stupid, but I haven't been able to find any sort of language on CMS to show a break out. Perhaps, I don't know enough about Medicare "speak" to understand what they mean. Any help would be most appreciated.
Click to expand...

There is a Medicare Part B Bulletin about this. Pub 100-04, Chapter 12, Section 110.3 posted 01/30/12. It says to bill for a PA Assistant at Surgery with modifiers -AS, -80...in that order. The Surgeon gets paid his full amount on his Claim, then the PA's claim gets paid 85% of 16% of the full allowable for the CPT. (Confused yet!?) So for CPT 29881, the allowable right now is $588.52. The Surgeon would get paid $588.52 on his claim. The PA would get paid $80.05 on their claim. $588.52 x 16% = $94.17. Then $94.17 x 85% = $80.05. Hopefully this helps!
Jenna
 
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