Physician Assistants practice in almost every area of medicine. We are a diverse group. E/M (Evaluation/Management) guidelines are the same no matter what your specialty, but there are some specific coding pearls you should be aware of depending on your specialty. Some of these pearls are specific to Massachusetts.

Surgery: Most surgical procedures carry a global period. This means that pre-op, the procedure and post-op are all bundled into one payment. There are instances, however, when extra charges are appropriate. For instance, a patient is being followed by an orthopedic practice for a fractured wrist. During a follow-up visit, which would have normally fallen under the "global period", the cast needs to be replaced. This would constitute a separate visit and should be billed with a modifier. This information needs to be communicated to billing personnel, so they can capture rightful reimbursement.:

Primary Care:

1. Many Internal Medicine practices use PA's to cover Nursing Home patients. Many practices lose out on potential reimbursement 2 ways. There are 2 separate groups of codes for Nursing Home patients. 99301-99303 are the annual assessment codes and can be used with a re-admit, annual exam, or if there has been a significant change in patient status. If the carrier decides these codes were not warranted, they will deny payment, and this needs to be watched closely. 99311-99313 are the codes for subsequent visits in a Skilled Nursing Facility. These carry a lower reimbursement and should be used at all follow-up visits, including extra visits due to illness or injury. If a PA does a procedure in the Nursing Home, it is billable along with the visit. Many practices just bill the visits and lose out on valuable reimbursement.
   
   
2. Care Plan Oversight Log: Are you spending large amounts of time on the phone with Home Health Agencies managing acute and chronic problems and seeing no reimbursement? Use these codes. Massachusetts requires the use of HCPCS codes for this and you must have the facility number for the Home Health Agency and document time spent. It is worth it, but ask to see the explanation of benefit when it comes in and be sure your efforts are being reimbursed. These codes can be temperamental, so if you are going to spend the time, be sure the bills are being handled appropriately.
   
   
3. Consultations: PA's can provide consultative services and they should be billed using the PA's PIN (Provider Identification Number)
   
   
4. Cerumen Removal: Blue Cross Blue Shield of Massachusetts will not pay for E/M services on the same day as cerumen removal. Their payment for the cerumen removal is higher than their payment for most E/M visits, so bill what is most appropriate, but not both. Most other carriers will pay for both with a 25 modifier on the E/M, but their payment is usually less than that of BC/BS.
   
   
5. Incident-To: Did you know that a nurse's or a medical assistant's services can be considered "incident-to" a Physician Assistant's services. For instance: The Physician is out of the office. The PA is seeing patients. The medical assistant sees a patient for a blood pressure check. The MA reports the reading to the PA who advises to continue current regimen and recheck in 1 month. The PA never sees the patient. This would be a 99211 under the PA's PIN.

Pediatrics:

1. Did you know that Massachusetts Medicaid will not reimburse for a well child exam and immunization administration on the same day? They consider it bundled into the physical.
   
   
2. Are you billing the appropriate EPSDT (Early and Periodic Screening Diagnosis and Treatment) modifiers for rightful reimbursement when doing a well child check? There is an enhanced rate when you provide all the required services and attach the modifier.

1. Starred Procedure: Some minor surgical procedures are considered "starred procedures". This means that some carriers allow a medical visit with the procedure. For instance, a shave biopsy is a "starred procedure". You may charge an E/M service, if it is documented and charge for follow-up if needed.
   
   
2. Advanced Beneficiary Notification (ABN): If you are seeing a Medicare patient and you have reason to believe that Medicare may deny payment for lack of medical necessity, you must have the patient sign an "ABN". This simply means that the patient agrees to pay for services if denied by Medicare. If you do not do this, you cannot bill the patient and you have lost reimbursement.
   
   
3. HPSA: Health Professional Shortage Areas. Many urban and rural clinics qualify as a HPSA site and are entitled additional incentive payments. Check out www.medicarenhic.com to see if your site qualifies.

As I said in the last newsletter, the focus on reimbursement is foreign to many PA's, and certainly should not be the main focus in patient care. There is, however a need to be informed and proactive about educating our employers to seek optimal ethical reimbursement for our services. In the next newsletter, I will do E/M coding challenges so you can test your skills. If there are particular issues you would like to see addressed, email me at kjeghers@compliantbilling.com.

© 2001, Karen Jeghers. All rights reserved.

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