Your SlideShare is downloading. ×
0
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Physician Assistant Billing Compliance Training
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Physician Assistant Billing Compliance Training

3,391

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
3,391
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
17
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. <ul><li>Billing Compliance Education </li></ul><ul><li>For </li></ul><ul><li>Physician Assistants </li></ul>
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. <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. 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. 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>

×