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Qualified Health Care Professional or Clinical Staff

Robert J Posted Wed 29th of June, 2016 10:02:26 AM
Our clinic is located in Texas and has hired a Licensed Surgical Assistant who is treating our clinic patients. I need to know if they qualify as a Qualified Health Care Professional or are they classified as Clinical Staff for billing medical services under the specific rules and guidelines by CMS. How should the services of the LSA be billed ? Also can they perform and bill E&M Services ?
SuperCoder Answered Thu 30th of June, 2016 02:52:18 AM
Hi, An assistant at surgery is a physician who actively assists the physician in charge of a case in performing a surgical procedure. (Note that a nurse practitioner, physician assistant or clinical nurse specialist who is authorised to provide such services under State law can also serve as an assistant at surgery). They come under the category of Non Physician Practitioners.There are few facts that reimbursement equals 16% of the amount otherwise applicable for the global surgery (So the NPP would be receiving 85% of 16%, i.e. 13.6% of the physician fee schedule amount). Use the "modifier 80" when the assistant at surgery service was provided by a medical doctor (MD).Use the modifier"81" to identify minimum surgical assistant services, and is only submitted with surgery codes.Use the modifier "82" when the assistant at surgery service was provided by an MD and there was not a qualified resident available. Documentation must include information relating to the unavailability of a qualified resident in this situation.Use the modifier "AS" for assistant at surgery services provided by a Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS). The provider must accept assignment. Medicare allows 85% of the 16% for the assistant at surgery services provided by a PA, NP, or CNS. Fee Schedule for Physician'' Services - Assistant at Surgery. Indicators for services where an assistant at surgery is allowed.
0 = Payment restrictions for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.
1 = Statutory payment restriction for assistants at surgery applies to this procedure. Assistant at Surgery may not be paid.
2 = Payment restrictions for assistants at surgery does not apply to this procedure. Assistant at Surgery may be paid.
Here are few links for further understanding.:Billing- http://www.ast.org/legislation/documents/TX_SA_Reimbursement_Law.pdf Texas legislation-http://www.ast.org/legislation/documents/TX_SA_Reimbursement_Law.pdf As for E/M services Medicare will pay for E/M services for specific non-physician practitioners (i.e., nurse practitioner (NP), clinical nurse specialist (CNS) and certified nurse midwife (CNM)) whose Medicare benefit permits them to bill these services. A physician assistant (PA) may also provide a physician service, however, the physician collaboration and general supervision rules as well as all billing rules apply to all the above non-physician practitioners. The service provided must be medically necessary and the service must be within the scope of practice for a nonphysician practitioner in the State in which he/she practices.(https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf) Hope this helps. Thanks.
Robert J Posted Thu 30th of June, 2016 10:40:12 AM
Under CMS billing guidelines can an individual/ Licensed Surgical Assistant (LSA) in Texas provide and bill for medical services rendered in a physician office clinic which are not surgically assisting a physician. Medical services examples such as patient visits/new and follow-up visits, global surgical visits, Cysto procedures, Testopel pellet implantation, penile injections, ultrasound procedures, PVR/Flow Rate, TRUS Biopsy. Medical Services that a nurse practioner, physician assistant, clinical nurse specialist might provide. Would the LSA be deemed a Qualified Medical Professional or Clinical Staff with this example. I understand the billing rules if they are surgically assisting a physician but need clarification if they are practicing and providing medical service(s) outside the scope of surgical assisting procedures are are providing services as indicated above.
SuperCoder Answered Fri 01st of July, 2016 01:45:06 AM
Hi, As I mentioned in my answer the service provided must be medically necessary and the service must be within the scope of practice for a nonphysician practitioner in the State in which he/she practices.Each insurance company and each individual plan has their own itemized list of covered benefits and non-covered items. Additionally, this directive changes frequently. Most insurance companies, however, do cover the charges for a surgical assistant. You may wish to review your individual insurance plan policy and discuss the exclusion of this particular service with a representative of your insurance carrier, your employee benefits administrator, your human resources manager, or your employer, as appropriate. Again, as a subscriber of your insurance company, you may authorize payment for our fees. Insurance companies often make their determination of medical necessity on the basis of their data, which may include overall average experience from surgeons and multiple patients over a period of time, rather than on a specific individual patient’s situation. In any event, the use of a surgical assistant is always at the discretion of the surgeon, rather than the insurance company.Hence, in your case the services such as penile injections, ultrasound procedures, PVR/Flow Rate, TRUS Biopsy depends on your insurance provider. Thanks

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