Randi Posted Tue 03rd of June, 2014 15:43:58 PM
We've never had a PA in our office before today and I need to know how to bill for her services. She is now employed by our practice. The MD is saying that he will step into each room before the PA provides service. Do I put an SA modifier on the E&M visit? Will the visit be paid at 85% or 100% of the allowable? Is there anything else I need to do billing wise to stay compliant and not commit fraud?
SuperCoder Answered Wed 04th of June, 2014 20:34:38 PM
PAs are licensed healthcare professionals who may, under a physician's supervision, practice medicine in any setting, including a physician office, clinic or hospital.
Scope-of-practice laws vary from state to state, but in most cases PAs can, for instance, take a patient's history, perform a physical exam, order and interpret tests, provide patient follow-up (including hospital rounds) and assist during surgery.
A PA bills for his services using a dedicated personal identification number (PIN). Generally, PA's receive reimbursement equal to 85 percent of the rate paid to a physician in the same circumstances.
For instance, if the insurer pays a physician first surgical assistant 16 percent of the primary surgeon's fee of $1,000, or $160, a PA serving as first assistant for the same surgery would receive $136 ($160 x 0.85).
Don't confuse PA services with "incident-to": Services provided by a PA billing under his own PIN are distinct from services provided incident-to a physician. You should report incident-to services under the physician's PIN. Payers reimburse incident-to services at 100 percent of the usual rate.
SuperCoder Answered Wed 04th of June, 2014 20:36:21 PM
You should use HCPCS Level II modifier SA for supervised nurse practitioner services when the insurer requires the modifier. Some Medicaid programs such as Medi-Cal require you to apply Modifier SA to all NP services which are submitted under the physician provider number.
Example: A nurse practitioner provides a level III established patient office visit to a Medi-Cal patient. The NP's FP supervises the service. To indicate the NP provided the office visit under direct supervision, you would append modifier SA (Nurse practitioner rendering service in collaboration with a physician) to 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).
Use modifier SA for incident-to services that are billed under the supervising physician's NPI number. The modifier tells the insurer that the NP rather than the physician provided the service and the physician supervised the NP. Incident-to services are paid at 100 percent of the Medicare Physician Fee Schedule amount.
Insurers may apply a reduction to services billed directly under the NP's NPI. Typical reduction is 15 to 20 percent.