Billing Compliance Education

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• Billing Compliance Education
• For
• Physician Assistants

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General Information

• UCD Health System Policy 1259
• Physician Assistant (PA) Services Guidelines
  for Professional Billing
• http//intranet.ucdmc.ucdavis.edu/policies/hosp/12
  59.html
• Reviewed Annually
• Changes in Regulations or Billing Policies
• UC Directives
• Clarification

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PA Policy Revisions

• History
• 2006
• Expanded Definitions
• Clarification
• 2005
• Minor Changes
• 2004
• Shared/Split Visits
• 2003
• Complexity Restrictions Lifted
• Consultations

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Definitions

• Types of Clinics
• Hospital-Based Clinics
• Operate under license of the hospital
• Includes all Academic Departments
• Free-Standing Clinics
• Do not operate under license of the hospital
• Primary Care Network Clinics

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Definitions

• Billing Components Based on Location
• Hospital or Hospital-Based Clinic
• Two Components
• Professional Fee
• Use of Facility
• Free-Standing Clinic
• One Global Fee

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Definitions

• Supervising Physician
• Fully Licensed Physician
• MD or DO
• Not participating in an ACGME, GME or ABMS
  Program
• Exception UCDHS Policy 1928, Teaching Physician
  Guidelines for Professional Fee Billing, Section
  IV, Moonlighting Residents or Fellows

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Definitions

• Types of Supervision
• Personal Supervision
• The physician must be present in the room when
  the service is provided
• Direct Supervision
• The physician must be present in the office or
  clinic suite and immediately available
• Floors not Doors
• General Supervision
• Services are under the physicians overall
  direction and control, but the physicians
  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 Services
• Currently licensed as a PA in the State of
  California
• Supervising PA Services
• All services billed under a PA provider number
  require a minimum of General Supervision
  regardless of payer source
• Pay attention to Type of Supervision Required
• Payer Specific
• One supervising physician may supervise no more
  than the equivalent of two PAs at any one time

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Scope of Practice

• General
• Governed by the California Business and
  Professions Code
• May perform medical services that
• She/he is competent to perform
• Are consistent with the PAs 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 physicians
  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 physicians fee schedule for
  PA services and 85 of the physicians fee
  schedule for non-physician services

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Terms

• Billing Terms
• Split/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 Clinics
• Requires
• Two separate notes
• PA AND supervising physician face-to-face time

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Documentation Guidelines

• Documentation - All Payers
• PA
• EMR and/or Chart
• All services ordered and/or provided, including
  verbal orders must be personally documented,
  signed and dated
• 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 Process
• Request For Information (RFI)
• Documentation - Medi-Cal
• Supervising 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 DOS
• The 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, cont
• 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
• 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 fee
• If billing under the Supervising Physician
• 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
• Must meet Incident-to rules

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Payor Specific Billing Guidelines

• Medicare - Free-Standing Clinics (PCN), cont
• 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
  physicians/PAs Direct Supervision
• Services must be billed under the name and
  provider number of the physician or PA providing
  Direct Supervision
• Name and number of physician or PA providing
  Direct Supervision must be reported on the claim

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Payor Specific Billing Guidelines

• Medicare - Free-Standing Clinic (PCN), cont
• Incident-to Rules, cont
• 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
  patients treatment
• Caution
• Free-Standing Clinics only (PCN)
• Definition of Direct Supervision
• When supervising physicians take vacation

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Payor Specific Billing Guidelines

• Medicare - Hospital, Emergency Room,
  Hospital-Based
• Clinics
• Must bill under the PA Provider Number
• Exceptions
• Split/Shared Visit
• Must meet Split/Shared Guidelines
• Reminder - If PA is on the UCDHS Cost Report PA
  cannot submit a professional fee

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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
• Supervising physician must document some
  face-to-face portion of the E/M Service
• PA must document some face-to-face portion of the
  E/M Service
• Does not apply to
• Critical Care Services
• Consultation Services
• Surgical Procedures
• Free-Standing Clinics (PCN)

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Payor Specific Billing Guidelines

• Medi-Cal All Locations
• PA
• 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
• http//files.medical.ca.gov/pubsdoco/publications/
  masters-MTP/Part2/nonph_m00o03o11.doc
• Difference between billable and payable

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Payor Specific Billing Guidelines

• Commercial Capitated Plans All Locations
• Coverage and reimbursement varies
• Most carriers cover services billed under the
  name of the physician providing general
  supervision
• Workers Compensation All Locations
• PA can provide services to workers compensation
  patients
• PA 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 Services
• UCDHS Policy 1924
• http//intranet.ucdmc.ucdavis.edu/policies/hosp/19
  24.html
• The 3 Rs
• 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 Report
• Medi-Cal
• PA - prohibited from performing and/or billing
  any consultation service
• Commercial Capitated Plans
• Coverage varies

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Modifiers

• Modifiers
• Medi-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
• -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 Procedure
• Billing 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
• http//www.ucdmc.ucdavis.edu/compliance/
• General Coding Education
• E/M Documentation Requirements
• UCDHS Audit Tool
• http//www.ucdmc.ucdavis.edu/cet/resources.

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Resources

• Web Resources
• Medicare
• www.medicarenhic.com
• Medi-Cal
• www.medi-cal.ca.gov
• Workers Compensation
• www.dir.ca.gov