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MCR Denying Fracture Codes from midlevels

  1. #1
    Post MCR Denying Fracture Codes from midlevels
    Medical Coding Books
    Hello. We're an Ortho GROUP (all providers billing under one Tax ID) in upstate NY who since the beginning of April, have been getting denials for fracture charges submitted by our midlevel practitioners (PA and NP). We called Medicare and spoke to several reps in the claims dept. and they're all telling me that MCR has reviewed their policies and they've recently determined that they shouldn't have been, nor will they in the future, continue to pay for a midlevel practitioner billing any "major surgical" code. They tell me they are defining "major surgical codes" as "any code with a 90 day global period".

    So then my question is in regard to this scenario: A patient comes into our practice and is treated by a midlevel for a fracture and a temporary splint is applied. Then 3 days later the Physician sees the patient again, re-evaluates and treats the fracture in a more permanent capacity.

    Would there be any problem with midlevel diagnosing the fracture and charging the office visit as well as the splint application and materials AND THEN the Physician charging a re-eval and the appropriate fracture treatment code a few days later?

  2. #2
    The physician would not be able to charge for the E&M code for the "re-eval" but they should be able to charge for the fx care, I would think. I think it would work similar to if an ER MD diagnosis the fx and stablizes it and then refers the patient to the ortho MD. We don't have Mid levels yet, but are soon going to get some, so I would like the definitive answer on this as well.
    Tina Wosmek CPC, COSC

  3. #3
    Thanks for the reply. And yeah.. I also thought of that scenario.. where the ER Docs stabilize and refer fractures back to be treated by ortho.. But then the difference is, the temporary stabilization is being done by someone in the same practice who is billing under the same tax ID and group NPI. So I wondered if it would be a different ruling since the midlevel is actually working under that same physician who happens to be their "supervising" (in the case of the PA, etc).

  4. #4
    Yes, good question! I wonder if the MD would need to sign off of the exam and treatment. Again, we currently don't have midlevels in our practice so I am very curious as to the answer to this as I know that our practice is growing and will be adding PAs and I am sure this senario will come into play at our clinic as well.
    Tina Wosmek CPC, COSC

  5. #5
    I had a chapter meeting today and brought up this question and everyone was pretty unanimous that the Midlevel would not be able to charge the procedure code unless they were credentialed and that the MD should be doing those and the MD should see them on the first visit and PA do the follow up. Which makes sense to me.
    Tina Wosmek CPC, COSC

  6. #6
    We are having the same issue. We've appealed all of our claims with no response yet. I've been in contact with the AAPA who provided me with this. Hope this helps!


    Medicare Denials for Fracture Management
    Medicare denials must be appealed. Medicare has a well-defined appeals process
    Recently, fracture management claims have been denied by certain Medicare contractors. Appeals must be pursued. Denials have been successfully overturned, but not until the 3rd level of the process, which involves an Administrative Law Judge (ALW). Typically, the ALW asks for “proof” that the PA is authorized to perform/provide fracture management services. “Proof” can be provided in a variety of ways, and should be readily available in a credentialing file at the practice site.
    State law
    Suggest keeping a copy of the PA Practice Act/Statutes in the file.
    State law summaries are listed by State on our website:

    Delegation/Practice Agreement
    Whether or not a practice agreement is required by your State Law, it is good practice to have one signed by both the PA and the Supervising Physician(s). A practice agreement that specifies the delegation of fracture management to the PA proved very helpful in one instance. Additionally, in states where protocols and agreements must be signed off by the State Medical Board, this serves as de facto authorization by the state Medical Board as well.
    Sample Practice Agreement:

    Medicare Benefit Policy Manual
    Chapter 15:Covered Medical and Other Health Services
    190 - Physician Assistant (PA) Services
    3. Types of PA Services That May Be Covered
    State law or regulation governing a PA's scope of practice in the State in which the services are performed applies. Carriers should consider developing lists of covered services. Also, if authorized under the scope of their State license, PAs may furnish services billed under all levels of CPT evaluation and management codes, and diagnostic tests if furnished under the general supervision of a physician.
    Examples of the types of services that PAs may provide include services that traditionally have been reserved to physicians, such as physical examinations, minor surgery, setting casts for simple fractures, interpreting x-rays, and other activities that involve an independent evaluation or treatment of the patient's condition.

    CPT Rules:
    CPT © AMA Manual 2011
    Introduction-pg x
    “Any procedure or service in any section of this book may be used to designate the services rendered by any qualified physician or other qualified healthcare professional.”

  7. #7
    OMG--I totally had a AAPC webinar on this just the other week and they covered this. "E&M for Orthopedics" here is the overview of the slides in question (slides 38 and 39).

    Utilizing non-physician practitioner
    *scope-of practice and level of physician supervision vary from state to state.
    *For payers who do not credential NPPS, services may be billed using the supervising physician's provider number.
    *for payers such as Medicare, who do credential NPPS, a service provided by an NPP should be billed using his or her provider number; however, there are a few exceptions.
    *Exceptions for reporting E/M services provided by NPPs:
    --Medicare's "Incedent to" provision
    -------*Office Setting only
    -------*Established patient with an established condition
    -------*Physician is in the office suite and is immediately available to assist
    --Medicare's split/shared service concept
    ------*Both the physician and the NPP each provide a substantive portion of an E/M service (face-to-face) to the same patient on the same date
    ------*Each must document their own contribution to the service

    Hope that helps--
    Tina Wosmek CPC, COSC

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