Hospital Services Provided by Physician Assistants (PAs)

Written by on August 29, 2014 in Features - No comments

What are the Rules?

In my consulting career, the number of hospital employers who do not bill properly for PA services consistently fascinates me.  I have also encountered some smaller hospitals that, until recently, never billed for PA inpatient services.

HospitalPAsWEBWhile the landscape for inpatient delivery of services is changing, it is important to realize that PAs are an integral part of the healthcare delivery team and these services rendered are indeed billable and reimbursable.

In September 2013, the Centers for Medicare & Medicaid Services (CMS) issued revised guidance and clarification that affirms the ability of PAs, nurse practitioners (NPs) and medical residents to write admission orders and perform the history and physical (H&P) for hospital inpatient admissions. The Hospital Inpatient Perspective Payment System (IPPS) rule for 2014 originally questioned and appeared to restrict the authority of PAs nurse practitioners (NPs) and medical residents to provide these important and critical admission services.

The primary purpose of the IPPS rule was to assist hospitals in defining the appropriate use of hospital admission versus observation status, thereby helping more Medicare beneficiaries become eligible for nursing home care after a minimum three-day hospital inpatient stay. Physician certification of the admission must occur after the order is written and the H&P has been performed. Currently, only a physician is authorized to authenticate the certification and the certification must occur prior to the patient’s discharge.

BILLING AND REIMBURSEMENT

How can billing be maximized in the hospital setting? The concept of “incident-to” billing is an outpatient-only application. While physician assistants (PAs) may not bill incident-to in a hospital, they may bill under the physician they are working with and collect 100 percent reimbursement if the shared billing criteria are met.

What is Shared Billing?

Shared billing is a provision that allows a medical service predominately provided by a PA to be billed under the name and Medicare number of the supervising physician at 100 percent, as opposed to 85 percent if the service had been billed under the PA’s name and NPI.

While a physician must provide a face-to-face service to a patient in addition to the PA’s service for a shared visit to be billed, it is appropriate for the PA to have performed the majority of care (as much as 90 percent, for example) for that patient. As long as the physician has some participation in the care of the patient, the combined services of both the physician and the PA may be attributed to the physician on the claim form.

How Do You Bill?

The Centers for Medicare & Medicaid Services (CMS) rules give PAs and their supervising physicians some flexibility in hospital billing for evaluation and management services.

The requirements, found in Medicare Transmittal 1776 [PDF], www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1776B3.pdf allow PAs and physicians who work for the same employer to “share” visits made to patients on the same calendar day by billing their combined work under the physician’s NPI number. The reimbursement will then be at 100 percent of the fee schedule, even if the PA performed the majority of the work.

Criteria for Shared Visits (These must all be met and clearly documented in the patient record):

  • Both the PA and the physician must have a common employer (e.g., same group practice, same hospital, or PA employed by a solo physician).
  • The service provided is not a consultation evaluation and management (E/M) service, procedure or a critical care service.
  • The physician must provide some face-to-face portion of the E/M visit; simply reviewing and/or signing the patient’s chart isn’t sufficient to qualify for a shared service.
  • Both the PA and the physician’s professional services for the patient must be clearly documented on the patient’s chart.
  • Both the PA and the physician must see the patient on the same calendar day.

The physician must provide some face-to-face portion of the E/M encounter. If this is not the case, then the service should then be billed at the full fee schedule amount under the PA’s NPI number, and that visit will be reimbursed at the 85 percent rate.

Shared billing allows maximum reimbursement to be achieved in the hospital setting when the team of the physician and the PA delivers the care for the patient.

References:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-09-05-13.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1776B3.pdf

By Lisa P. Shock, MHS, PA-C
President/CEO Utilization Solutions in Healthcare, Inc.

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