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Medicare Reimbursement -PA/NP

  1. Default Medicare Reimbursement -PA/NP
    Medical Coding Books
    Hi, Can anybody clear on medicare reimbursement for PA and NP if they are not credentialed with medicare and if needs to go under Physician name, will any modifier be appended to justify a PA or NP has seen patient.

    Thanks,
    Gopinath

  2. #2
    Location
    Columbia, MO
    Posts
    12,924
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    Quote Originally Posted by Gopinath View Post
    Hi, Can anybody clear on medicare reimbursement for PA and NP if they are not credentialed with medicare and if needs to go under Physician name, will any modifier be appended to justify a PA or NP has seen patient.

    Thanks,
    Gopinath
    If the PA or NP is seeing the patient and you are billing under the physician, then this is an incident to claim and the visit must meet the incident to definition. Meaning in short this visit is a follow up encounter to a physician encounter for the same dx. The PA/NP cannot make any changes to the treatment plan and cannot examine any new dx. These claims do not need any modifier and are paid the same as a physician encounter since they are viewed as an extension of the physician's visit, and they are paid the same as a physician rate. If your PA/NP does not meet the definition of incident to then you cannot be billing it using the physician NPI.
    Incident to:
    * The physician must have already examined the patient at a previous encounter for the same dx.
    * The physician must have a plan of care in the patient chart that the PA/NP is following
    * The physician must be within the office suite area while the patient is being attended by the PA/NP

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Location
    Charlotte, NC
    Posts
    534
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    Deb,

    Quick question-Does this also go for in-office procedures like a hemorrhoidectomy? It's part of the physicians treatment plan and the mid-level is doing nothing new according to the treatment plan set up by the MD.

    I say no because it's a procedure and not an E/M but have not been able to actually find anything in writing.

    Thanks,
    Fred

  4. #4
    Location
    Columbia, MO
    Posts
    12,924
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    Quote Originally Posted by coachlang3 View Post
    Deb,

    Quick question-Does this also go for in-office procedures like a hemorrhoidectomy? It's part of the physicians treatment plan and the mid-level is doing nothing new according to the treatment plan set up by the MD.

    I say no because it's a procedure and not an E/M but have not been able to actually find anything in writing.

    Thanks,
    Fred
    Well yes but, this is where state licensure laws take over. Some procedures by state law require the physican to perform them, some require over the shoulder supervision and others just require that the physician be in the office. You should check first.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    Location
    Charlotte, NC
    Posts
    534
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    OK, thanks. I know the mid-level can perform the procedure (only from what I've read), just didn't know about the billing portion with the physician.

    Thanks for clearing that up though!!

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