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04/10/23 1
Coding Education & Training Program, HIM Department
Billing Compliance EducationFor
Physician Assistants
04/10/23 2
Coding Education & Training Program, HIM Department
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
04/10/23 3
Coding Education & Training Program, HIM Department
PA Policy Revisions
History2006 Expanded Definitions Clarification2005 Minor Changes2004 Shared/Split Visits2003 Complexity Restrictions Lifted Consultations
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Coding Education & Training Program, HIM Department
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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Coding Education & Training Program, HIM Department
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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Coding Education & Training Program, HIM Department
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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Coding Education & Training Program, HIM Department
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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Coding Education & Training Program, HIM Department
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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Coding Education & Training Program, HIM Department
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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Coding Education & Training Program, HIM Department
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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Coding Education & Training Program, HIM Department
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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Coding Education & Training Program, HIM Department
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
04/10/23 13
Coding Education & Training Program, HIM Department
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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Coding Education & Training Program, HIM Department
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
04/10/23 15
Coding Education & Training Program, HIM Department
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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Coding Education & Training Program, HIM Department
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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Coding Education & Training Program, HIM Department
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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Coding Education & Training Program, HIM Department
Payor Specific Billing Guidelines
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
04/10/23 19
Coding Education & Training Program, HIM Department
Payor Specific Billing Guidelines
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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Coding Education & Training Program, HIM Department
Payor Specific Billing Guidelines
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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Coding Education & Training Program, HIM Department
Payor Specific Billing Guidelines
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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Coding Education & Training Program, HIM Department
Payor Specific Billing Guidelines
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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Coding Education & Training Program, HIM Department
Payor Specific Billing Guidelines
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
04/10/23 24
Coding Education & Training Program, HIM Department
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
04/10/23 25
Coding Education & Training Program, HIM Department
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
04/10/23 26
Coding Education & Training Program, HIM Department
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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Coding Education & Training Program, HIM Department
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.
04/10/23 28
Coding Education & Training Program, HIM Department
Resources
Web Resources
Medicare
www.medicarenhic.comMedi-Cal
www.medi-cal.ca.govWorkers’ Compensation
www.dir.ca.gov