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<ul><li>Billing Compliance Education </li></ul><ul><li>For </li></ul><ul><li>Physician Assistants </li></ul>
General Information <ul><li>UCD Health System Policy 1259 </li></ul><ul><ul><li>Physician Assistant (PA) Services:  Guidel...
PA Policy Revisions <ul><li>History </li></ul><ul><ul><li>2006 </li></ul></ul><ul><ul><ul><li>Expanded Definitions </li></...
Definitions <ul><li>Types of Clinics </li></ul><ul><ul><li>Hospital-Based Clinics </li></ul></ul><ul><ul><ul><li>Operate u...
Definitions <ul><li>Billing Components ~ Based on Location </li></ul><ul><ul><li>Hospital or Hospital-Based Clinic </li></...
Definitions <ul><li>Supervising Physician </li></ul><ul><ul><li>Fully Licensed Physician </li></ul></ul><ul><ul><ul><li>MD...
Definitions <ul><li>Types of Supervision </li></ul><ul><ul><li>Personal Supervision </li></ul></ul><ul><ul><ul><li>The phy...
Minimum Qualifications <ul><li>Providing PA Services </li></ul><ul><ul><li>Currently licensed as a PA in the State of Cali...
Scope of Practice <ul><li>General </li></ul><ul><ul><li>Governed by the California Business and Professions Code </li></ul...
Scope of Practice <ul><ul><li>In California, PAs are permitted to provide the following services: </li></ul></ul><ul><ul><...
Scope of Practice <ul><ul><li>In addition, written protocols and standing orders may be developed by the supervising physi...
Terms <ul><li>Billing Terms </li></ul><ul><ul><li>“Incident-to” </li></ul></ul><ul><ul><ul><li>Medicare term ~ Applies onl...
Terms <ul><li>Billing Terms </li></ul><ul><ul><li>Split/Shared Visit </li></ul></ul><ul><ul><ul><li>Another Medicare term ...
Documentation Guidelines <ul><li>Documentation - All Payers </li></ul><ul><ul><li>PA </li></ul></ul><ul><ul><ul><li>EMR an...
Rules & Regulations <ul><li>General Requirements for Physicians Supervising PA  </li></ul><ul><li>Services </li></ul><ul><...
Rules & Regulations <ul><li>General Requirements for Physicians Supervising  </li></ul><ul><li>PA Services, con’t </li></u...
Payor Specific Billing Guidelines <ul><li>Medicare  - Free-Standing Clinics (PCN) </li></ul><ul><ul><li>Can bill under PA ...
Payor Specific Billing Guidelines <ul><li>Medicare - Free-Standing Clinics (PCN), con’t </li></ul><ul><ul><li>“ Incident-t...
Payor Specific Billing Guidelines <ul><li>Medicare - Free-Standing Clinic (PCN), con’t </li></ul><ul><ul><li>“Incident-to”...
Payor Specific Billing Guidelines <ul><li>Medicare - Hospital, Emergency Room, Hospital-Based  </li></ul><ul><li>Clinics <...
Payor Specific Billing Guidelines <ul><li>Medicare - Hospital, Emergency Room, Hospital-Based  </li></ul><ul><li>Clinics <...
Payor Specific Billing Guidelines <ul><li>Medi-Cal – All Locations </li></ul><ul><ul><li>PA </li></ul></ul><ul><ul><ul><li...
Payor Specific Billing Guidelines <ul><li>Commercial & Capitated Plans – All Locations </li></ul><ul><ul><li>Coverage and ...
Consultation Guidelines <ul><li>Consultation Services </li></ul><ul><ul><li>UCDHS Policy 1924 </li></ul></ul><ul><ul><ul><...
Modifiers <ul><li>Modifiers </li></ul><ul><ul><li>Medi-Cal/GMC </li></ul></ul><ul><ul><ul><li>When billing PA services und...
<ul><li>Pay Attention – Each Payer has specific rules  </li></ul><ul><li>& guidelines that vary depending on: </li></ul><u...
Questions <ul><li>Questions </li></ul><ul><ul><li>Compliance Issues </li></ul></ul><ul><ul><ul><li>Code of Conduct </li></...
Resources <ul><li>Web Resources </li></ul><ul><li>Medicare </li></ul><ul><ul><li>www.medicarenhic.com </li></ul></ul><ul><...
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Physician Assistant Billing Compliance Training

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Transcript of "Physician Assistant Billing Compliance Training"

  1. 1. <ul><li>Billing Compliance Education </li></ul><ul><li>For </li></ul><ul><li>Physician Assistants </li></ul>
  2. 2. General Information <ul><li>UCD Health System Policy 1259 </li></ul><ul><ul><li>Physician Assistant (PA) Services: Guidelines for Professional Billing </li></ul></ul><ul><ul><ul><li>http://intranet.ucdmc.ucdavis.edu/policies/hosp/1259.html </li></ul></ul></ul><ul><li>Reviewed Annually </li></ul><ul><ul><li>Changes in Regulations or Billing Policies </li></ul></ul><ul><ul><li>UC Directives </li></ul></ul><ul><ul><li>Clarification </li></ul></ul>
  3. 3. PA Policy Revisions <ul><li>History </li></ul><ul><ul><li>2006 </li></ul></ul><ul><ul><ul><li>Expanded Definitions </li></ul></ul></ul><ul><ul><ul><li>Clarification </li></ul></ul></ul><ul><ul><li>2005 </li></ul></ul><ul><ul><ul><li>Minor Changes </li></ul></ul></ul><ul><ul><li>2004 </li></ul></ul><ul><ul><ul><li>Shared/Split Visits </li></ul></ul></ul><ul><ul><li>2003 </li></ul></ul><ul><ul><ul><li>Complexity Restrictions Lifted </li></ul></ul></ul><ul><ul><ul><li>Consultations </li></ul></ul></ul>
  4. 4. Definitions <ul><li>Types of Clinics </li></ul><ul><ul><li>Hospital-Based Clinics </li></ul></ul><ul><ul><ul><li>Operate under license of the hospital </li></ul></ul></ul><ul><ul><ul><li>Includes all Academic Departments </li></ul></ul></ul><ul><ul><li>Free-Standing Clinics </li></ul></ul><ul><ul><ul><li>Do not operate under license of the hospital </li></ul></ul></ul><ul><ul><ul><li>Primary Care Network Clinics </li></ul></ul></ul>
  5. 5. Definitions <ul><li>Billing Components ~ Based on Location </li></ul><ul><ul><li>Hospital or Hospital-Based Clinic </li></ul></ul><ul><ul><ul><li>Two Components </li></ul></ul></ul><ul><ul><ul><ul><li>Professional Fee </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Use of Facility </li></ul></ul></ul></ul><ul><ul><li>Free-Standing Clinic </li></ul></ul><ul><ul><ul><ul><li>One Global Fee </li></ul></ul></ul></ul>
  6. 6. Definitions <ul><li>Supervising Physician </li></ul><ul><ul><li>Fully Licensed Physician </li></ul></ul><ul><ul><ul><li>MD or DO </li></ul></ul></ul><ul><ul><ul><li>Not participating in an ACGME, GME or ABMS Program </li></ul></ul></ul><ul><ul><ul><ul><li>Exception – UCDHS Policy 1928, Teaching Physician Guidelines for Professional Fee Billing, Section IV, Moonlighting Residents or Fellows </li></ul></ul></ul></ul>
  7. 7. Definitions <ul><li>Types of Supervision </li></ul><ul><ul><li>Personal Supervision </li></ul></ul><ul><ul><ul><li>The physician must be present in the room when the service is provided </li></ul></ul></ul><ul><ul><li>Direct Supervision </li></ul></ul><ul><ul><ul><li>The physician must be present in the office or clinic suite and immediately available </li></ul></ul></ul><ul><ul><ul><ul><li>“ Floors not Doors” </li></ul></ul></ul></ul><ul><ul><li>General Supervision </li></ul></ul><ul><ul><ul><li>Services are under the physician’s overall direction and control, but the physician’s 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 </li></ul></ul></ul><ul><ul><li>One of these types of supervision requirements apply whether billing under the name of the PA or supervising physician </li></ul></ul>
  8. 8. Minimum Qualifications <ul><li>Providing PA Services </li></ul><ul><ul><li>Currently licensed as a PA in the State of California </li></ul></ul><ul><li>Supervising PA Services </li></ul><ul><ul><li>All services billed under a PA provider number require a minimum of “General Supervision” regardless of payer source </li></ul></ul><ul><ul><li>Pay attention to Type of Supervision Required </li></ul></ul><ul><ul><ul><li>Payer Specific </li></ul></ul></ul><ul><ul><li>One supervising physician may supervise no more than the equivalent of two PAs at any one time </li></ul></ul>
  9. 9. Scope of Practice <ul><li>General </li></ul><ul><ul><li>Governed by the California Business and Professions Code </li></ul></ul><ul><ul><li>May perform medical services that </li></ul></ul><ul><ul><ul><li>She/he is competent to perform </li></ul></ul></ul><ul><ul><ul><li>Are consistent with the PA’s education, training and experience </li></ul></ul></ul><ul><ul><ul><li>Have been delegated to the PA in writing by a supervising physician who is responsible for the patients cared for by the PA </li></ul></ul></ul>
  10. 10. Scope of Practice <ul><ul><li>In California, PAs are permitted to provide the following services: </li></ul></ul><ul><ul><ul><li>Administer and provide medication to patients and transmit prescriptions with an order from a supervising physician </li></ul></ul></ul><ul><ul><ul><li>Perform surgical procedures under local anesthesia without the personal presence of the supervising physician </li></ul></ul></ul><ul><ul><ul><li>Order laboratory procedures </li></ul></ul></ul><ul><ul><ul><li>Order therapies and nursing services </li></ul></ul></ul><ul><ul><ul><li>Take history and physical examinations </li></ul></ul></ul><ul><ul><ul><li>Make assessments and diagnoses therefrom </li></ul></ul></ul><ul><ul><ul><li>Initiate, review and revise treatment plans </li></ul></ul></ul><ul><ul><ul><li>Act as a first or second assistant in surgery under the supervision of an approved supervising physician </li></ul></ul></ul>
  11. 11. Scope of Practice <ul><ul><li>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 </li></ul></ul>
  12. 12. Terms <ul><li>Billing Terms </li></ul><ul><ul><li>“Incident-to” </li></ul></ul><ul><ul><ul><li>Medicare term ~ Applies only to Medicare </li></ul></ul></ul><ul><ul><ul><li>Rule that allows services that are provided by a PA to be billed under the supervising physician’s provider number or allows services provided by a non-physician (RN/MA) to be billed under the PA provider number </li></ul></ul></ul><ul><ul><ul><li>Paid at 100% of the physician’s fee schedule for PA services and 85% of the physician’s fee schedule for non-physician services </li></ul></ul></ul>
  13. 13. Terms <ul><li>Billing Terms </li></ul><ul><ul><li>Split/Shared Visit </li></ul></ul><ul><ul><ul><li>Another Medicare term ~ Applies to Evaluation & Management (E/M) Services only </li></ul></ul></ul><ul><ul><ul><li>Allows documentation from the physician and PA note to be combined </li></ul></ul></ul><ul><ul><ul><li>Hospital, Emergency Room & Hospital-Based Clinics </li></ul></ul></ul><ul><ul><ul><ul><li>Requires </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Two separate notes </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>PA AND supervising physician face-to-face time </li></ul></ul></ul></ul></ul>
  14. 14. Documentation Guidelines <ul><li>Documentation - All Payers </li></ul><ul><ul><li>PA </li></ul></ul><ul><ul><ul><li>EMR and/or Chart </li></ul></ul></ul><ul><ul><ul><ul><li>All services ordered and/or provided, including verbal orders must be personally documented, signed and dated </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Additionally, the PA must identify their supervising physician for all entries </li></ul></ul></ul></ul><ul><ul><li>Supervising Physician must </li></ul></ul><ul><ul><ul><li>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 </li></ul></ul></ul><ul><ul><li>Query Process </li></ul></ul><ul><ul><ul><ul><li>Request For Information (RFI) </li></ul></ul></ul></ul><ul><li>Documentation - Medi-Cal </li></ul><ul><ul><li>Supervising Physician must review and countersign all entries within seven days of the date of service </li></ul></ul>
  15. 15. Rules & Regulations <ul><li>General Requirements for Physicians Supervising PA </li></ul><ul><li>Services </li></ul><ul><li>Services billed under a PA provider number in a hospital-based or free-standing Clinic require general supervision for all payer sources </li></ul><ul><li>Services provided “Incident To” the professional services of a physician in a free-standing clinic require direct supervision of the PA </li></ul><ul><li>The physician assistant and the supervising physician </li></ul><ul><li>must establish written guidelines for adequate supervision and include at least one of the following: </li></ul><ul><ul><li>The supervising physician examines the patient and documents such the same DOS </li></ul></ul><ul><ul><li>The supervising physician countersigns all medical records written by PA within 30 days of DOS </li></ul></ul>
  16. 16. Rules & Regulations <ul><li>General Requirements for Physicians Supervising </li></ul><ul><li>PA Services, con’t </li></ul><ul><ul><li>The supervising physician adopts protocols </li></ul></ul><ul><ul><ul><li>Protocols must be signed and dated by the supervising physician and the PA </li></ul></ul></ul><ul><ul><ul><li>If protocol is adopted, the supervising physician must </li></ul></ul></ul><ul><ul><ul><ul><li>Review, countersign, and date at least 10% of all records of patients treated by PA within 30 days of DOS </li></ul></ul></ul></ul>
  17. 17. Payor Specific Billing Guidelines <ul><li>Medicare - Free-Standing Clinics (PCN) </li></ul><ul><ul><li>Can bill under PA or Supervising Physician </li></ul></ul><ul><ul><ul><li>Reimbursement is greater for services billed under the name of the supervising physician </li></ul></ul></ul><ul><ul><ul><li>If PA is on the UCDHS Cost Report PA cannot submit a professional fee </li></ul></ul></ul><ul><ul><li>If billing under the Supervising Physician </li></ul></ul><ul><ul><ul><ul><li>Must meet “Incident-to” rules </li></ul></ul></ul></ul><ul><ul><li>Services provided by non-physicians (RN/MA) that are “Incident-to” PA services are covered and separately billable under the PA </li></ul></ul><ul><ul><ul><ul><li>Must meet “Incident-to” rules </li></ul></ul></ul></ul>
  18. 18. Payor Specific Billing Guidelines <ul><li>Medicare - Free-Standing Clinics (PCN), con’t </li></ul><ul><ul><li>“ Incident-to” Rules </li></ul></ul><ul><ul><ul><li>Allowed to provide any service within the scope of practice of the PA/non-physician employee </li></ul></ul></ul><ul><ul><ul><li>Service must be an integral part of the Physicians/PA professional services </li></ul></ul></ul><ul><ul><ul><li>Commonly included in a physician bill </li></ul></ul></ul><ul><ul><ul><li>Commonly furnished in a physician office or clinic </li></ul></ul></ul><ul><ul><ul><li>Furnished by a PA/non-physician under physician’s/PA’s “ Direct Supervision ” </li></ul></ul></ul><ul><ul><ul><li>Services must be billed under the name and provider number of the physician or PA providing “Direct Supervision” </li></ul></ul></ul><ul><ul><ul><ul><li>Name and number of physician or PA providing “Direct Supervision” must be reported on the claim </li></ul></ul></ul></ul>
  19. 19. Payor Specific Billing Guidelines <ul><li>Medicare - Free-Standing Clinic (PCN), con’t </li></ul><ul><ul><li>“Incident-to” Rules, con’t </li></ul></ul><ul><ul><ul><li>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 patient’s treatment </li></ul></ul></ul><ul><ul><li>Caution </li></ul></ul><ul><ul><ul><li>Free-Standing Clinics only (PCN) </li></ul></ul></ul><ul><ul><ul><li>Definition of “Direct Supervision” </li></ul></ul></ul><ul><ul><ul><ul><li>When supervising physician’s take vacation </li></ul></ul></ul></ul>
  20. 20. Payor Specific Billing Guidelines <ul><li>Medicare - Hospital, Emergency Room, Hospital-Based </li></ul><ul><li>Clinics </li></ul><ul><ul><li>Must bill under the PA Provider Number </li></ul></ul><ul><ul><ul><li>Exceptions </li></ul></ul></ul><ul><ul><ul><ul><li>Split/Shared Visit </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Must meet Split/Shared Guidelines </li></ul></ul></ul></ul><ul><ul><ul><li>Reminder - If PA is on the UCDHS Cost Report PA cannot submit a professional fee </li></ul></ul></ul>
  21. 21. Payor Specific Billing Guidelines <ul><li>Medicare - Hospital, Emergency Room, Hospital-Based </li></ul><ul><li>Clinics </li></ul><ul><ul><li>Split/Shared Visit Guidelines </li></ul></ul><ul><ul><ul><li>Applies to Evaluation & Management (E/M) Services provided in the hospital, ER, or hospital-based clinic </li></ul></ul></ul><ul><ul><ul><li>Must have two separate notes </li></ul></ul></ul><ul><ul><ul><ul><li>Supervising physician must document some face-to-face portion of the E/M Service </li></ul></ul></ul></ul><ul><ul><ul><ul><li>PA must document some face-to-face portion of the E/M Service </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Does not apply to </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Critical Care Services </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Consultation Services </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Surgical Procedures </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Free-Standing Clinics (PCN) </li></ul></ul></ul></ul></ul>
  22. 22. Payor Specific Billing Guidelines <ul><li>Medi-Cal – All Locations </li></ul><ul><ul><li>PA </li></ul></ul><ul><ul><ul><li>Must bill under their supervising physician name </li></ul></ul></ul><ul><ul><ul><li>There are specific HCPCS, CPT-4 and Medi-Cal only codes </li></ul></ul></ul><ul><ul><ul><li>For a list of these codes go to </li></ul></ul></ul><ul><ul><ul><ul><li>http://files.medical.ca.gov/pubsdoco/publications/masters-MTP/Part2/nonph_m00o03o11.doc </li></ul></ul></ul></ul><ul><ul><li>Difference between billable and payable </li></ul></ul>
  23. 23. Payor Specific Billing Guidelines <ul><li>Commercial & Capitated Plans – All Locations </li></ul><ul><ul><li>Coverage and reimbursement varies </li></ul></ul><ul><ul><li>Most carriers cover services billed under the name of the physician providing general supervision </li></ul></ul><ul><li>Workers Compensation – All Locations </li></ul><ul><ul><li>PA can provide services to workers’ compensation patients </li></ul></ul><ul><ul><li>PA may not: </li></ul></ul><ul><ul><ul><li>Initiate new treatment </li></ul></ul></ul><ul><ul><ul><li>Report on an injured workers’ entitlement to benefits </li></ul></ul></ul><ul><ul><ul><li>Change the Primary Treating Physician (PTP) treatment plan </li></ul></ul></ul>
  24. 24. Consultation Guidelines <ul><li>Consultation Services </li></ul><ul><ul><li>UCDHS Policy 1924 </li></ul></ul><ul><ul><ul><li>http://intranet.ucdmc.ucdavis.edu/policies/hosp/1924.html </li></ul></ul></ul><ul><ul><ul><li>The 3 “R”s </li></ul></ul></ul><ul><ul><ul><ul><li>2003 - PA can be an appropriate requesting source for a consultation providing the PA has a billing provider number </li></ul></ul></ul></ul><ul><ul><li>Medicare </li></ul></ul><ul><ul><ul><li>PA can perform and bill under the PA provider number as long as all other consultation requirements are satisfied </li></ul></ul></ul><ul><ul><ul><li>Exception – PA on the Hospital Cost Report </li></ul></ul></ul><ul><ul><li>Medi-Cal </li></ul></ul><ul><ul><ul><li>PA - prohibited from performing and/or billing any consultation service </li></ul></ul></ul><ul><ul><li>Commercial & Capitated Plans </li></ul></ul><ul><ul><ul><li>Coverage varies </li></ul></ul></ul>
  25. 25. Modifiers <ul><li>Modifiers </li></ul><ul><ul><li>Medi-Cal/GMC </li></ul></ul><ul><ul><ul><li>When billing PA services under the name of the supervising physician the modifier -AN is required </li></ul></ul></ul><ul><ul><ul><li>When there are multiple modifiers selected, the Billing System automatically assigns the modifier –YU to indicate there are multiple modifiers </li></ul></ul></ul><ul><ul><li>Medicare </li></ul></ul><ul><ul><ul><li>Medicare mandates the use of a specific modifier to identify a PA as an assistant-at-surgery </li></ul></ul></ul><ul><ul><ul><ul><li>-AS </li></ul></ul></ul></ul><ul><ul><li>Workers Compensation </li></ul></ul><ul><ul><ul><li>When billing PA services for workers compensation, the modifier –98 is required </li></ul></ul></ul>
  26. 26. <ul><li>Pay Attention – Each Payer has specific rules </li></ul><ul><li>& guidelines that vary depending on: </li></ul><ul><ul><li>Type of Service Provided </li></ul></ul><ul><ul><ul><li>Office Visit </li></ul></ul></ul><ul><ul><ul><li>Consultation </li></ul></ul></ul><ul><ul><ul><li>Surgical Procedure </li></ul></ul></ul><ul><ul><li>Billing and/or Provider Name </li></ul></ul><ul><ul><ul><li>PA </li></ul></ul></ul><ul><ul><ul><li>Supervising Physician </li></ul></ul></ul><ul><ul><li>Location </li></ul></ul><ul><ul><ul><li>Hospital </li></ul></ul></ul><ul><ul><ul><li>Hospital-Based Clinic </li></ul></ul></ul><ul><ul><ul><li>Emergency Room </li></ul></ul></ul><ul><ul><ul><li>Free-Standing Clinic (PCN) </li></ul></ul></ul>
  27. 27. Questions <ul><li>Questions </li></ul><ul><ul><li>Compliance Issues </li></ul></ul><ul><ul><ul><li>Code of Conduct </li></ul></ul></ul><ul><ul><ul><li>HIPAA </li></ul></ul></ul><ul><ul><ul><ul><li>http://www.ucdmc.ucdavis.edu/compliance/ </li></ul></ul></ul></ul><ul><ul><li>General Coding Education </li></ul></ul><ul><ul><ul><li>E/M Documentation Requirements </li></ul></ul></ul><ul><ul><ul><li>UCDHS Audit Tool </li></ul></ul></ul><ul><ul><ul><ul><li>http://www.ucdmc.ucdavis.edu/cet/resources. </li></ul></ul></ul></ul>
  28. 28. Resources <ul><li>Web Resources </li></ul><ul><li>Medicare </li></ul><ul><ul><li>www.medicarenhic.com </li></ul></ul><ul><li>Medi-Cal </li></ul><ul><ul><li>www.medi-cal.ca.gov </li></ul></ul><ul><li>Workers’ Compensation </li></ul><ul><ul><li>www.dir.ca.gov </li></ul></ul>
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