Association of Neurosurgical Physician Assistants

1
Association of Neurosurgical Physician Assistants

• Reimbursement Issues Affecting
• Surgical Physician Assistants
• Orlando, Florida
• September 20, 2008
• Michael L. Powe, Vice President
• Health Systems Reimbursement
  Policy
• American Academy of Physician
  Assistants

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Understanding Reimbursement,Whats in it for You?

• Reflects your ability to generate revenue, and
  demonstrate economic and non-economic value to
  physicians, hospitals, and administrators
• Increases your understanding of the requirements
  of payment policy to help
• avoid allegations of fraud and abuse

3
Fraud and Abuse - The New Standard

• What you knew, or should have known
• It is your career, and your responsibility

4
Fraud and Abuse/Mistakes

• Intentional
• Unintentional
• Negligence

5
2008 Medicare Fee Schedule

• Congress passed legislation preventing the fee
  schedule from dropping by 10.6
• That legislation provided a .5 increase in 2008
  and increase of 1.1 in 2009
• AAPA continues to work with the AMA and other
  health care organizations to try and prevent
  future cuts to the fee schedule

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• Trends in practice
• management reimbursement

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Physician Quality Reporting Initiative

• Pay for performance or reporting
• Linking pay to performance, or at least pay for
  reporting, patient care information (PQRI)
• Up to 1.5 bonus payment in 2008 to report data
  on meeting quality standards
• Program is voluntary, but some expect it to
  become mandatory in the next few of years

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Medicare Pay for Reporting

• Currently 134 measures available additional
  measures expected to be added
• www.cms.hhs.gov/PQRI/Downloads/2008PQRIMeasureslis
  t.pdf (click on accept at lower left corner of
  the page)
• Use G or CPT II codes to report measures

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PQRI

• Reporting example
• Screening for future fall risk
• Percentage of patients aged 65 years or older
  who were screened for future fall risk at least
  once within 12 months (patients are considered at
  risk for future falls if they have had 2 or more
  falls in the past year, or any fall with injury
  in past year).

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PQRI

• Reporting example
• Perioperative Care Timing of Antibiotic
  Prophylaxis
• Percentage of patients 18 or older undergoing
  procedures with the indications of prophylactic
  parenteral antibiotics within one hour prior to
  the surgical incision
• -

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PQRI

• Additional Measures
• - Selection of prophylactic antibiotic first or
  second generation cephalosporin
• - Discontinuation of prophylactic antibiotics
  non-cardiac procedures

12
PQRI Examples

• CT or MRI reports
• Carotid imaging reports
• Consideration of rehabilitation services
• Deep vein thrombosis prophylaxis for ischemic
  stroke or intracranial hemorrhage

13
Hospital Mistakes

• Medicare will no longer pay hospitals for care
  caused by preventable errors.
• Never events contracts would eliminate payment
  if, for example, an items was mistakenly left in
  a patient during surgery
• The cost of returning to the OR is placed on the
  hospital (hospital cant bill patients)

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Hospital Mistakes

• Bed Sores, pressure ulcers, and mismatched blood
  transfusions are also included in the preventable
  mistake category
• UTIs from catheters are also on the list
• Concern over medical problems that the patient
  may have had before entering the hospital

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HHS Office of Inspector General

• Auditing arm of the Medicare and Medicaid
  programs
• Work plan established each year for their
  issues of concern
• 2008 issues incident to billing PA coverage
  under state Medicaid programs

16
RNFAs

• RNFA are not allowed to bill Medicare Part B
• RNFA advocates will continue to push for
  reimbursement on a state by state basis
• Cost pressures may cause more hospitals to hire
  RNFAs to meet surgical needs in a cost-effective
  manner

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Other Health Care Professionals

• OPAs (orthopedic physician assistants), surgical
  techs, and SAs (surgical assistants) who arent
  PAs are not covered by Medicare Part B
• These individuals may be included in a hospitals
  cost reports (similar to LPNs, RNs), but cant
  bill separately for a first assist, a procedure,
  or evaluation and management services

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Medicare Status for PAs

• PAs have a separate defined benefit category for
  coverage
• Ability to bill for services is legislatively
  defined in the Medicare statute

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Medicare Payment Percentage

• For virtually all services in all settings,
  Medicare will cover PAs at 85 of the physician
  fee schedule (state law always dictates scope of
  practice hospital requirements must be met)
• Services are billed at the full physician rate.
  Use of the PAs provider number triggers the 85
  payment
• Medicare
  Transmittal AB-98-15

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Enrollment into Medicare

• Fill out 855 form
• Must have a NPI number to enroll
• Generally must agree to accept electronic funds
  transfer and assignment

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National Provider Identifier (NPI)

• As of May 23, 2008, all health care professionals
  who submit electronic health care information
  (claims) must have a NPI number
• NPI will replace PINs, UPINs and the host of
  other public and private payer provider numbers

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National Provider Identifier

• 10-position (digit) number
• Will be used on every electronic claim and health
  care transaction
• Will stay with the health care professional
  permanently even if there is a change in
  employment or geographical practice location

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NPI Number

• NPI numbers also issued to clinics, hospitals,
  nursing homes, DME suppliers, etc.
• On claim forms, your NPI will be on the claim
  form possibly in addition to the practices NPI

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National Provider Identifier

• NPIs will not provide information on the type of
  health care professional or specialty
• You will probably have to separately enroll in
  various health plans
• Can apply on line for NPI. Check with billing
  office to determine if bulk (group) application
  for NPI will be submitted

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NPI Web Site

• https//nppes.cms.hhs.gov
• Fox Systems 800/465-3203

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National Provider Identifier

• Privacy concerns-
• Most data on NPI application form (addresses,
  license number) is now public, except for your
  DOB and Social Security number
• Consider removing home phone number and address.
  Consider using a business mailing address

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Medicare Scope of Practice

• PAs may bill (as allowed by state law)
• All E/M codes
• Consultations
• Initial hospital pre-surgical HPs (physician
  countersignature required)
• All diagnostic tests/procedures

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CPT Codes

• PAs have access to virtually all CPT codes to
  describe the services they deliver
• 2008 CPT Manual, professional edition,
  introduction
• Beware of Local Medical Review Policy trying to
  impose limitations
• State law must always be followed

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Non-Physician Providersand CPT

• Per CPT
• Any procedure or service in any section of this
  book may be used to designate the services
  rendered by any qualified physician or other
  qualified health care professional.

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CPT

• Additional language will appear in the 2009 CPT
  book (in the evaluation and management section)
  that will further confirm that PAs have access to
  all codes

31
Part A/Part B

• Medicare requires that medical and surgical
  services delivered by PAs (including NPs and
  physicians) be billed under Medicare Part B
• In the past, Medicare allowed hospital-employed
  PA salaries to be covered under Part A through
  the hospitals cost reports. That changed some
  years ago.

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Medicare Hospital Billing

• PAs can deliver care with the service covered at
  85 whether or not they are employed by the
  hospital
• No need for on site physician presence under
  Medicare (hospital bylaws/policies and state law
  must be followed)

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Medicare Hospital Billing When PA and the
Physician Treat Patients on the Same Day

• Is it a physician or PA bill if both provide
  service to the same patient on the same day?
• Medicares previous rules said whoever did the
  the majority of the work (ie., exam and medical
  decision making) had to bill

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Hospital Billing

• 2001 split billing policy created confusion,
  frustration and administrative difficulties
• October 2002 policy face-to-face interaction
  allowing more PA interaction with 100 billing
• AAPA pushed CMS to adopt a more user-friendly
  policy

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Shared Visit Policy

• Ability to combine hospital services provided
  by the PA and the physician to the same patient
  on the same day (this is not incident to
  billing).
• Requires that the physician provide a
  face-to-face portion of the E/M service to the
  patient
• Medicare Transmittal 1776, October
  25, 2002

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Shared Visit

• Applies to evaluation and management services
  (not procedures, critical care or consultations)
• Services of the PA and the physician must in the
  same calendar day
• PA and physician must be employed by the same
  entity (same hospital, same group practice, PA
  employed by solo physician)

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Consultations Shared Visits

• Dec. 20, 2005 transmittal officially removed
  consultations and critical care from shared
  visits
• Transmittal 788
• www.cms.hhs.gov/transmittals/downloads/R788CP.pdf
  
• AAPA argues against consult exclusion and will
  continue to try to make a policy change

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Modifier Code First Assisting

• AS is the only unique modifier that Medicare uses
  for PAs (PAs may also use the numeric modifiers
  that physicians use)
• Medicares payment is 85 of the 16 a
  physicians receive for first assisting
• Net is 13.6 of the primary surgeons fee

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Private Payer Hospital Surgical Billing

• For first assisting at surgery typically use 80,
  81, 82, or AS modifier, depending on instructions
  from the payer
• Dont assume that private payers use Medicares
  AS modifier
• Private payers pay between 10 and 25 of the
  surgeons fee (depending on the contract)

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Medicares First Assist Exclusion List

• Medicare list of approx. 1,800 surgical CPT codes
  for which a first assistant (physician/PA) fee is
  not payable
• Go to AAPA Web site (www.aapa.org), key word
  mcsurglist for the list of excluded codes

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Private Payers Denials

• Trend of reducing surgeries eligible for a first
  assistant
• ACS produces a booklet Physicians as Assistants
  at Surgery that can be used as a guide to
  challenge denials
• Categories almost always sometimes almost
  never

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Pre-OP HPs

• Normally, pre-op HPs are included in the bundled
  surgical payment
• There are limited occasions when the HP is
  separately billable

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Pre-Op HPs

• If you are requested by the practice performing
  the surgery to perform the surgical HP it is
  generally billable

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Pre-Operative HPs

• May be separately billable if
• - HP occurs more than 24 hours before the
  surgery, and
• - There is medical necessity some other
  medical condition (other than the problem that
  necessitates the need for surgery) that requires
  monitoring
• Medicare Transmittal 1719, August 31, 2001,
  Section 15047

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Pre-Op HPs

• Use E/M codes or consult codes, as appropriate
• Use ICD-9 code for pre-op (V72.81-72.84), and
• Use ICD-9 code for the medical condition that
  prompt the HP (hypertension, COPD, or other
  condition)

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-57 Decision For Surgery

• Visits one day prior to or day of surgery can
  be reported when
• E/M service resulted in initial decision to
  perform major surgery
• Modifier -57 is added to E/M service

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Global Surgical Package

• Pre-op work includes
• Hospital admission paperwork
• Reviewing records
• Obtaining consent
• Check instruments, positioning patient

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Post-operative Period

• Included in the global surgical period
• Post-op hospital rounding, hospital services and
  office visits related to the surgery are not
  separately billable for a period of 10 or 90
  days, depending on the surgical procedure
• Sometime difficult to determine what
  conditions/problems are directly related to the
  surgery
• Taking a patient back to the OR is billable

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Post-Op Period for Private Payers

• Some private payers will allow separate billing
  for surgical complications even if the patient is
  not taken back to the OR
• CPT instructions will allow for separate billing
  of certain complications
• Services unrelated to the surgery are billable
  within the global period

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Global Surgical Package

• Included in post-op
• Immediate post-op care
• Talking to family, other health care
  professionals
• Dictating operative notes
• Writing orders
• Evaluating post-anesthesia (recovery area)

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Teaching Hospital Rules

• Restrictions only apply to first assisting at
  surgery
• Resident billing rules do not apply to PAs
• In approved, accredited surgical residency
  programs, residents must be used for first
  assisting before PAs, physicians or NPs
• Medicare Carriers Manual
  Section 15106

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Teaching Hospital Rules

• PAs can be used for first assists even if
  there is an accredited program if
• -The surgeon never involves residents in the care
  of patients
• -The residents have a scheduled training session
  or educational conference/class
• - Trauma surgery

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Teaching Hospitals

• First assist modifier is -82 (in addition to AS)
• If there is an accredited training program and a
  resident is not used, place a notation in the
  chart/operative report briefly explaining why the
  resident was not used

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Private Payers

• Many require billing under the physicians
  name/provider number or the hospitals tax ID
• Billing under the physician for private payers is
  not necessarily the same as Medicares incident
  to policy

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Private Payers

• It is not fraud to bill under the
  physician/hospital if that is the payers
  required method of PA claim submission
• Unique issues in hospital/surgical billing
• - Modifier codes often required

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Private Payers

• Do not bill the first assist claim under another
  surgeons name unless specific written
  authorization is obtained from the payer
• Consider submitting a copy of the operative
  report along with the PA first assist claim

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Credentialing Payment

• Credentialing is not necessarily directly related
  to payment policy
• Credentialing and the issuance of provider
  numbers depend on the particular payers policy

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Contract Negotiations

• Continue to ask that your practice place language
  in the contract with private payers (renewed each
  year) recognizing PAs as providers of care.
• Could be official language or a written addendum
  signed/initialed by both parties

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Surgical Reimbursement Mandates

• AL, CT, IA, IL, FL, KY, MT, NC, TX
• DE may be added to the mandated payment list
• State mandates will not impact ERISA protected,
  self-insured plans
• Mandate for first assisting only

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AAPA Data base

• Contains information on over 350 private and
  public payers
• Available to AAPA members via the Members Only
  web site

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AAPA Data Base

• Private Payers
• www.aapa.org/members/gandp/privatepayer.html
• Medicaid
• www.aapa.org/members/gandp/medicaidprofile.html

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Resources/Contact Information

• AAPA Web site www.aapa.org
• Click on Professional Issues, then
  Reimbursement
• Phone [phone] ask for reimbursement
  department
• E-mail michael_at_aapa.org

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Productivity

• What does it mean?
• How is it measured?
• Why is it important?

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Tracking Productivity

• Productivity includes services performed by you
  that are
• - billed under your name
• - billed under the supervising physician
• - not separately billable

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Tracking Productivity

• Suggest that billing personnel have a method of
  accounting for your services within the practice
• Separate identification numbers within the
  office, or a modifier code attached to a
  physician name or provider number
• Doesnt matter if payers issue provider numbers

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Tracking Productivity

• Pre-op HPs and post-op services provided in the
  hospital or in the office may or may not be
  separately billable
• Medicare divides a surgical procedure into the
  fee for pre-operative services, intra-operative
  services and post-operative services

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Tracking Productivity

• Medicare fee
• - 11 for pre-op
• - 76 for intra-operative ( the actual surgery)
• - 13 for post-op care
• 24 of the global surgical fee is for
  non-intra-operative services

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Tracking Productivity

• Example
• 63005 Lumbar Laminectomy 970.00
• Pre 106.70
• Intra 737.96
• Post 126.10
• Final figure impacted by geographic region of
  the country

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Tracking Productivity

• If PA does pre-op screening (HP) and post-op
  care, 232.80 could be credited/allocated to PA
• Billing records would show 970.00 being credited
  to the physician, with 131.92 officially
  credited to the PA for the first assist (13.6
  Medicare payment rate)

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Tracking Productivity

• In reality
• 131.92 (first assist),
• 232.80 (pre- and post-op work)
• 364.72 could be credited to the PA

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Tracking Productivity

• Opportunity cost
• If you didnt provide the post-op service your
  supervising surgeon/physician would
• If you provide the non-billable post-op care,
  then physician is able to deliver new, revenue
  generating services (E/M, surgical case)

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Commitment

• Am I committed to this
  reimbursement thing
  or what?!

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• Questions?