Why did you become a PA? Was it to see 8 patients an hour and find yourself worrying about those monthly productivity charts? Of course not. We all have our own reasons for entering the profession, but most would say they love Medicine and they love taking care of patients.

One of the advantages of hiring a PA is supposed to be that they have more time to spend on patient education and counseling. This is rarely true these days. We are pressured to produce more and to show our employers why it is still cost effective to hire us. After all, Medicare only reimburses PA services at 85% and other third party payers are soon to follow suit. Our employers are under intense pressure to provide quality medical care, stay compliant, keep patients satisfied and show a profit. This is an awesome task, but one that PA's can help accomplish. Providing quality medical care and keeping patients satisfied is the easy part for PA's. Becoming proactive in Billing Compliance issues will help ensure that the profit for your services is ethically maximized. After all, you are the only one who knows what goes on in the exam room, and therefore billing personnel depend on you to adequately document each encounter. A few simple lessons will get you started:

	Learn E/M documentation guidelines. Carry a sliderule or a cheat sheet with the requirements for each level of service. Conduct audits within your office to be sure your documentation supports the level billed. Remember if it wasn't documented, it wasn't done and if it wasn't medically necessary, it shouldn't have been done.
	Understand "Incident-To" rules. The key components for billing "incident-to" are: Established patient with established problem, previously addressed by Physician, and Physician available in suite. Say the patient has seen the Physician for hypertension, and follows up with the PA. The Physician is in the suite, but does not see the patient. The PA treats the established hypertension and also treats a new problem of an otitis media. This is not "incident-to", unless the Physician sees the patient and evaluates and manages the new problem. If such visits are billed as "incident-to", you and your supervising physician are ultimately liable in an audit. Again, compliance is your responsibility.
	Be as specific as possible in your diagnoses and code symptoms when you are not certain of the diagnosis. Never code "rule-out" diagnoses. This can carry consequences for the patient. For example, you code "rule out" Lung cancer and this gets billed as lung cancer. This would be devastating for a patient applying for life insurance. Obviously, your note would reflect your concerns, but your coding should reflect symptoms, such as weight loss, cough and hemoptysis until a definitive diagnosis is made.
	Understand the concept of modifiers and learn how to use the ones most common to your practice. For instance, lets say you suture a laceration and treat a bronchitis at the same visit. You need to link the E/M code to the bronchitis and the laceration to the wound repair code and add a 25 modifier (separate identifiable service) to the E/M code. The effective use of modifiers, communicates to the insurance company why specific procedures were done at the same visit or why a patient may have been seen twice in one day. Without correct modifiers, many services are not appropriately reimbursed. These are services you provide and that your employer paid you to provide. Be sure they are being billed appropriately.

Here are a few practical coding challenges. See how you do:

Challenge 1: A 50 year old patient was seen for his diabetes at 10AM. At 3PM the patient returns due to an ankle injury. The insurance company denies the second visit. What can you do to be sure your practice receives appropriate reimbursement?

Challenge 2: A 70 year old established patient comes into the office with her family. The patient has recently taken several falls, and the family is questioning her safety at home. You spend an hour with the patient and family, listening to concerns and offering your opinion. The history, physical and decision making only justify a 99213 visit. What should you do in this situation to ensure proper reimbursement for this lengthy visit?

Challenge 3: A 35 year old patient comes to your office for a mole removal. You perform the procedure, send the mole to pathology and schedule suture removal in 10 days. In the mean time, the patient develops a cough and is seen 5 days later by another PA in your practice. What does the second PA need to communicate to billing personnel about this visit in order to ensure proper reimbursement?

Answer 1: Most Third Party Payers will only reimburse one E/M visit per day. In this situation, both visits were medically necessary. You should send the documentation indicating the distinct services and add a modifier 25 (separate identifiable service) to the second E/M code.

Answer 2: There are 2 possible solutions to this scenario. First, you could bill the 99213 by your documentation, and add 99354(prolonged service code). This would be justified if you spend 30-74 additional minutes (on top of time for E/M code) with the patient. The other alternative is to carefully document the time spent and to bill the visit based on time. The hour would justify a 99215 ( if you choose this way, do not add 99354). Be sure to note all time spent and to carefully document the medical necessity of the time.

Answer 3: The mole removal carries a 10 day global period. That means that all visits done in that time period are considered part of the original procedure and are not separately reimbursed. If the patient is seen for an unrelated problem, you need to add modifier 24 to the E/M code, or the visit will be denied. If you do not remember the modifier, remember the principle, and simply write "not related to mole removal 5 days ago". You would think that the separate diagnosis would be enough to clarify the situation, but it is not.

© 2001, Karen Jeghers. All rights reserved.

This article originally appeared in the Oct. 2001 issue of The MAPA Newsletter.