Physician Assistant Billing Compliance Training

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Coding Education & Training Program, HIM Department

Billing Compliance EducationFor

Physician Assistants

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General Information

UCD Health System Policy 1259Physician Assistant (PA) Services: Guidelines for Professional Billing http://intranet.ucdmc.ucdavis.edu/policies/hosp/1259.html

Reviewed AnnuallyChanges in Regulations or Billing PoliciesUC DirectivesClarification

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PA Policy Revisions

History2006 Expanded Definitions Clarification2005 Minor Changes2004 Shared/Split Visits2003 Complexity Restrictions Lifted Consultations

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Definitions

Types of ClinicsHospital-Based Clinics Operate under license of the hospital Includes all Academic DepartmentsFree-Standing Clinics Do not operate under license of the

hospital Primary Care Network Clinics

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Definitions

Billing Components ~ Based on LocationHospital or Hospital-Based Clinic Two Components

1. Professional Fee2. Use of Facility

Free-Standing Clinic1. One Global Fee

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Definitions

Supervising PhysicianFully Licensed Physician MD or DO Not participating in an ACGME, GME or

ABMS Program1. Exception – UCDHS Policy 1928, Teaching

Physician Guidelines for Professional Fee Billing, Section IV, Moonlighting Residents or Fellows

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Definitions

Types of SupervisionPersonal Supervision The physician must be present in the room when

the service is providedDirect Supervision The physician must be present in the office or

clinic suite and immediately available1. “Floors not Doors”

General Supervision Services are under the physician’s overall

direction and control, but the physician’s presence is not required during the performance of the procedure or service. The physician can be available in-person or through electronic means to authorize the service

One of these types of supervision requirements apply whether billing under the name of the PA or supervising physician

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Minimum Qualifications

Providing PA ServicesCurrently licensed as a PA in the State of California

Supervising PA ServicesAll services billed under a PA provider number require a minimum of “General Supervision” regardless of payer sourcePay attention to Type of Supervision Required Payer SpecificOne supervising physician may supervise no more than the equivalent of two PAs at any one time

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Scope of Practice

GeneralGoverned by the California Business and Professions CodeMay perform medical services that She/he is competent to perform Are consistent with the PA’s education,

training and experience Have been delegated to the PA in writing by

a supervising physician who is responsible for the patients cared for by the PA

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Scope of Practice

In California, PAs are permitted to provide the following services: Administer and provide medication to patients and

transmit prescriptions with an order from a supervising physician

Perform surgical procedures under local anesthesia without the personal presence of the supervising physician

Order laboratory procedures Order therapies and nursing services Take history and physical examinations Make assessments and diagnoses therefrom Initiate, review and revise treatment plans Act as a first or second assistant in surgery under the

supervision of an approved supervising physician

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Scope of Practice

In addition, written protocols and standing orders may be developed by the supervising physician(s) subject to approval by the UCDHS Inter-Disciplinary Practices Board and the UCDHS Medical Staff Executive Committee

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Terms

Billing Terms“Incident-to” Medicare term ~ Applies only to Medicare Rule that allows services that are

provided by a PA to be billed under the supervising physician’s provider number or allows services provided by a non-physician (RN/MA) to be billed under the PA provider number

Paid at 100% of the physician’s fee schedule for PA services and 85% of the physician’s fee schedule for non-physician services

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Terms

Billing TermsSplit/Shared Visit Another Medicare term ~ Applies to

Evaluation & Management (E/M) Services only

Allows documentation from the physician and PA note to be combined

Hospital, Emergency Room & Hospital-Based Clinics1. Requires

Two separate notes PA AND supervising physician face-to-face

time

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Documentation Guidelines

Documentation - All PayersPA EMR and/or Chart

1. All services ordered and/or provided, including verbal orders must be personally documented, signed and dated

2. Additionally, the PA must identify their supervising physician for all entries

Supervising Physician must Review, countersign and date the medical record

within 7 days ANYTIME a Schedule II drug order has been issued or carried out by a PA

Query Process1. Request For Information (RFI)

Documentation - Medi-CalSupervising Physician must review and countersign all entries within seven days of the date of service

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Rules & Regulations

General Requirements for Physicians Supervising PA Services Services billed under a PA provider number in a hospital-

based or free-standing Clinic require general supervision for all payer sources

Services provided “Incident To” the professional services of a physician in a free-standing clinic require direct supervision of the PA

The physician assistant and the supervising physician must establish written guidelines for adequate supervision and include at least one of the following:

The supervising physician examines the patient and documents such the same DOSThe supervising physician countersigns all medical records written by PA within 30 days of DOS

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Rules & Regulations

General Requirements for Physicians Supervising PA Services, con’t

The supervising physician adopts protocols Protocols must be signed and dated by the supervising

physician and the PA If protocol is adopted, the supervising physician must

1. Review, countersign, and date at least 10% of all records of patients treated by PA within 30 days of DOS

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Payor Specific Billing Guidelines

Medicare - Free-Standing Clinics (PCN)Can bill under PA or Supervising Physician Reimbursement is greater for services billed under

the name of the supervising physician If PA is on the UCDHS Cost Report PA cannot

submit a professional feeIf billing under the Supervising Physician

1. Must meet “Incident-to” rules

Services provided by non-physicians (RN/MA) that are “Incident-to” PA services are covered and separately billable under the PA

1. Must meet “Incident-to” rules

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Medicare - Free-Standing Clinics (PCN), con’t“Incident-to” Rules Allowed to provide any service within the scope of

practice of the PA/non-physician employee Service must be an integral part of the

Physicians/PA professional services Commonly included in a physician bill Commonly furnished in a physician office or clinic Furnished by a PA/non-physician under

physician’s/PA’s “Direct Supervision” Services must be billed under the name and

provider number of the physician or PA providing “Direct Supervision”1. Name and number of physician or PA providing

“Direct Supervision” must be reported on the claim

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Medicare - Free-Standing Clinic (PCN), con’t“Incident-to” Rules, con’t The supervising physician or supervising

PA must personally perform the initial service for each new condition, make an initial diagnosis and set up a treatment plan and thereafter personally perform services of a frequency reflecting their active participation in, and management of the patient’s treatment

Caution Free-Standing Clinics only (PCN) Definition of “Direct Supervision”

1. When supervising physician’s take vacation

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Medicare - Hospital, Emergency Room, Hospital-Based Clinics

Must bill under the PA Provider Number Exceptions

1. Split/Shared Visit2. Must meet Split/Shared Guidelines

Reminder - If PA is on the UCDHS Cost Report PA cannot submit a professional fee

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Medicare - Hospital, Emergency Room, Hospital-Based Clinics

Split/Shared Visit Guidelines Applies to Evaluation & Management (E/M) Services

provided in the hospital, ER, or hospital-based clinic Must have two separate notes

1. Supervising physician must document some face-to-face portion of the E/M Service

2. PA must document some face-to-face portion of the E/M Service

3. Does not apply to Critical Care Services Consultation Services Surgical Procedures Free-Standing Clinics (PCN)

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Medi-Cal – All LocationsPA Must bill under their supervising physician

name There are specific HCPCS, CPT-4 and Medi-

Cal only codes For a list of these codes go to

1. http://files.medical.ca.gov/pubsdoco/publications/masters-MTP/Part2/nonph_m00o03o11.doc

Difference between billable and payable

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Commercial & Capitated Plans – All LocationsCoverage and reimbursement variesMost carriers cover services billed under the name of the physician providing general supervision

Workers Compensation – All LocationsPA can provide services to workers’ compensation patientsPA may not: Initiate new treatment Report on an injured workers’ entitlement to

benefits Change the Primary Treating Physician (PTP)

treatment plan

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Consultation Guidelines

Consultation ServicesUCDHS Policy 1924 http://intranet.ucdmc.ucdavis.edu/policies/hosp/1924.html The 3 “R”s

1. 2003 - PA can be an appropriate requesting source for a consultation providing the PA has a billing provider number

Medicare PA can perform and bill under the PA provider number

as long as all other consultation requirements are satisfied

Exception – PA on the Hospital Cost ReportMedi-Cal PA - prohibited from performing and/or billing any

consultation serviceCommercial & Capitated Plans Coverage varies

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Modifiers

ModifiersMedi-Cal/GMC When billing PA services under the name of the

supervising physician the modifier -AN is required When there are multiple modifiers selected, the

Billing System automatically assigns the modifier –YU to indicate there are multiple modifiers

Medicare Medicare mandates the use of a specific modifier

to identify a PA as an assistant-at-surgery 1. -AS

Workers Compensation When billing PA services for workers

compensation, the modifier –98 is required

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Pay Attention – Each Payer has specific rules & guidelines that vary depending on:

Type of Service Provided Office Visit Consultation Surgical ProcedureBilling and/or Provider Name PA Supervising Physician Location Hospital Hospital-Based Clinic Emergency Room Free-Standing Clinic (PCN)

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Questions

Questions

Compliance Issues Code of Conduct HIPAA

1. http://www.ucdmc.ucdavis.edu/compliance/

General Coding Education E/M Documentation Requirements UCDHS Audit Tool

1. http://www.ucdmc.ucdavis.edu/cet/resources.

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Resources

Web Resources

Medicare

www.medicarenhic.comMedi-Cal

www.medi-cal.ca.govWorkers’ Compensation

www.dir.ca.gov

Physician Assistant Billing Compliance Training

Documents

Transcript of Physician Assistant Billing Compliance Training