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PA Assist Documentation Requirements

  1. #1
    Default PA Assist Documentation Requirements
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    I code for an Orthopedic group. They usually use PA's to assist. My question is this: what are the documentation requirements for coding and billing of PA assist surgeries? All my surgeons do is in the heading of the report, below the diagnosis and procedural statement, is "Assistant= So and So, PA-C". Is this considered compliant in so far as sending out a claim form for the PA? Or does the PA need to document what he assisted the surgeon on? I feel uncomfortable sending out claims for the assist without any documentation, but my supervisor is adamant that I do so. Thanks in advance!!


    Rich

  2. #2
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    The PA does not need to document his/her own note, but the surgeons note must state what assistance the PA provided; what he/she did to assist. This would be necessary even if the assistant was another MD. The only time you need two separate notes is when it a s a co-surgeon surgical procedure.
    Lisa Bledsoe, CPC, CPMA

  3. #3
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    Quote Originally Posted by ercoder65 View Post
    I code for an Orthopedic group. They usually use PA's to assist. My question is this: what are the documentation requirements for coding and billing of PA assist surgeries? All my surgeons do is in the heading of the report, below the diagnosis and procedural statement, is "Assistant= So and So, PA-C". Is this considered compliant in so far as sending out a claim form for the PA? Or does the PA need to document what he assisted the surgeon on? I feel uncomfortable sending out claims for the assist without any documentation, but my supervisor is adamant that I do so. Thanks in advance!!


    Rich
    You will have to make sure that the surgical code is assitant-surgery acceptable (you can find on Medicare website). PA's get AS modifiers not 80. Hope this helps. There was a great article on this subject in the Coding Edge magazine a few months ago (Oct??).

  4. #4
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    Thanks Lisa! So basically what they are making me do is really non-compliant?

  5. #5
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    Here is part of a memo I sent my surgeons:

    However, for every operative note it must be clearly documented as to the reason the assistant was required and what role the assistant played. It is not sufficient to simply state that the assistant was a medical necessity for the entirety of the surgical case. The assistant's role must also be documented in the body of the operative report. Use of the term “we” and stating that the assistant performed a certain technique and/or specific assistance with a technique will be helpful in obtaining reimbursement for assistant services.
    Also, you must use modifier AS for non-physician assistants (PA's, NPP's). Modifier -80 is for physicians as assistants only.


    I wouldn't necessarily say you are being asked to do something that is non-compliant, the doctors need to be educated on the requirements for their op note documentation.
    Lisa Bledsoe, CPC, CPMA

  6. #6
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    Quote Originally Posted by Lisa Curtis View Post
    Here is part of a memo I sent my surgeons:

    However, for every operative note it must be clearly documented as to the reason the assistant was required and what role the assistant played. It is not sufficient to simply state that the assistant was a medical necessity for the entirety of the surgical case. The assistant’s role must also be documented in the body of the operative report. Use of the term “we” and stating that the assistant performed a certain technique and/or specific assistance with a technique will be helpful in obtaining reimbursement for assistant services.
    Also, you must use modifier AS for non-physician assistants (PA’s, NPP’s). Modifier -80 is for physicians as assistants only.


    I wouldn't necessarily say you are being asked to do something that is non-compliant, the doctors need to be educated on the requirements for their op note documentation.

    I think Lisa has provided a great example. Some carriers are vague or provide little guidance on what is expected for assistant documentation. Like Lisa, we have a policy, across the board and expect some type of documentation regarding the role of each assistant. For those procedures that have an assistant payment indicator of zero (0-assistant surgery may be paid w/ supporting documentation), it is critical that the documentation can stand on its own. Appeals are far easier with good documentation...

  7. #7
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    Okay, but the issue is my supervisor is not a coder and knows nothing about coding; worse is she won't listen to any professional advice nor take steps to correct this since she is (understandably) intimidated by physicians. If this is not necessarily non-compliant, then would you as a professional coder maintain status quo even though you know that its not the correct way to document PA assists? I am not sure of what my options are at this point.

  8. #8
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    I fight this fight everyday. Even if your boss is a non-coder I would think she would understand the concept of "if its not documented it didn't happen". We can only code based on what we can prove happened based on the documentation. The header of an op report is not what we code from, we code based on the body. If you can't tell there was more than one person doing the work based on the body of the op report how can you bill for more than one person? Maybe approaching it from that standpoint will make more sense to her. The administrators I work with are non-coders but they fully understand the concept of documentation supporting what is billed.

    If you can't convince them maybe its time to bring in an outside opinion, get an external consultant to do an audit and outline your areas of risk. It sucks to have to do this but sometimes thats what it takes to get them to listen to you.

    Good luck,

    Laura, CPC, CEMC

  9. #9
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    In addition to what Laura stated...

    Once your practice is on the carriers "radar" for lack of assistant surgery documenation (as an example), you can believe that they will begin to deny these services routinely. Grant it...assistant PA surgery isn't a huge money maker but over a period of time, the adjustments are bound to catch someone's eye. I imagine she'll be explaining 2 things to the providers/upper mgmt when/if this happens...1) why the adjustments/denials have increased 2) why it wasn't brought to the physicians attention sooner...

  10. #10
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    Since this facility seems to care most about the bottom line, I doubt my supervisor will give the go ahead for an outside audit (due to paying $$$). What is my next plan of attack?

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