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SEPTEMBER 14, 2019
Pediatric Billing for PAsChristopher D Newman, PA-C FCCMAssociate Professor of Clinical Practice PediatricsDirector of Advanced Practice Strategy- PICUCU School of Medicine/Childrens Hospital Colorado
DiscolosuresA portion of my salary is paid by CU Medicine, Inc. the billing entity for the University of Colorado faculty practice.
The information presented today is my own and is not presented on behalf of, nor endorsed by CU Medicine, Inc.
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Definitions
Basic Principles
Practice Area Specific Guide
Pitfalls
Content Outline
Some Definitions before we begin• Professional Service Fees- fees for services rendered by a physician or LIP,
what we typically think of as “billing”• Facility Fees- when care is provided in a facility, such as a hospital, surgical
center or skilled nursing facility, the facility will itself submit a separate bill for their fees
• LIP- licensed independent practitioner. A confusing term, first used by the Centers for Medicare & Medicaid Services (CMS), to describe those non-physicians eligible to submit professional service fees. CMS includes Physician Assistants in the LIP list and the “independent” describes the ability to provide a service, not the supervisory (or lack theirof) relationship
• NPI- National Provider Identifier- a standard, federally issued identifier for a provider or facility that is used to identify the party seeking reimbursement for services
• Many insurance plans require an additional identifier, but all are indexed against the NPI
• Stark Law, Anti Kickback Statute- two federal laws designed to prevent physicians from financially benefitting from referrals and testing orders
• Most relevant portion for PAs is that if a physician pays a facility for a service, the physician must pay “fair market value”
• Medicare Administrative Contractor (MAC)- A private insurer awarded a geographic contract to process Medicare part A and B claims- often set individual documentation standards
• Medicare- a federally administered health insurance program primarily for older adults. Although few pediatric patients qualify, most private insurance and state Medicaid programs take their cues from Medicare
• Pediatric patients who may have medicare include ESRD patients and permanently disabled patients between the ages of 20 and 22
• “Incident to”- a mechanism for a PA to perform a service for a physician’s already established patient and have the physician reimbursed at 100% of the fee schedule- no excuse to use in pediatrics
• wRVU- work Relative Value Unit- a measure used to compare expected level of effort for a given service/patient encounter
Basic Principles• PAs ARE licensed independent practitioners per the CMS definition and are
reimbursed at 85% of physician fee schedule when billed directly• PA services are reimbursed by all 50 state Medicaid programs, though the ease
of reimbursement can vary and supervision requirements can impact• Tricare (military insurance program) reimburses at 85% of the physician fee
schedule• Medicare and most private insurance companies pay “first assist” fees,
provided no qualified resident or fellow is available• Several state Medicaid programs no longer pay “first assist” fees or restrict
the types of surgeries they will pay this fee for
How Employment Impacts Billing• PAs that are employed by a physician or practice organization, leased by a
practice or physician, independent contractors or those with an ownership stake in a practice can obtain an NPI number and bill for their services
• PAs cannot bill under a hospital or facility NPI• PAs employed by a hospital, whose salaries are included on the hospital’s
Medicare Part A expense report, cannot bill for services• PAs employed by a hospital, but “leased” to a physician or practice, can bill
for services as long as the lease amount reflects “fair market value”
Other Basic Principles• Physicians cannot “attest to” or “cosign” a PA note and bill for the services
identified in the note• Student billing is actively in flux and will be discussed at the end
Guidelines by Practice Area
Critical Care• While patients often complex, the billing is pretty simple• What matters is patient condition and care delivered, not location• You can bill for critical care outside of an ICU• Divided into two groups• <6 covered by age-based bundle codes
• Can only be billed by a physician• Pays much more for initial date of service• Only things not included are ECMO and CPR
• 6 or over time based billing• Only elements needed to bill are time spent, why pt is critically ill, what you did• One code (99291) first 30-74 min, one code (99292) for addl 30 minute increments• More than 1 provider can bill, but must document that time is non-overlapping• Need to be careful about patient/family discussion
Inpatient• Only one provider from a service can bill for each day’s care• Use “initial” codes for first day of hospitalization, not first day of your service• While individual states may require “cosignature”, physicians can’t bill for
“cosigned” or attested inpatient notes• Day of discharge billed using discharge codes
• New rule requires documentation of total minutes spent, no longer accepts a range or greater than/less than
• Only 1 service can bill discharge
Split/Shared• Discussed in inpatient, but same rules apply to outpatient, ED or observation• Formal consultation services, critical care and SNF visits cannot be split
shared• To use, both an APP and physician must perform a “substantial portion” of the
visit and document their portion• Both portions can be used for E&M coding, • A cosignature or attestation is insufficient to justify split/shared• Combined time can be used for prolonged services• Only the billing provider’s time spent in care coordination can be used to
justify a time-based E&M code
Time based E&M Coding• Can only be used if >50% of a visit’s time was spent in care coordination• Must document total time spent and time spent in care coordination• Insufficient to document “more than 50 % of time spent in care coordination”• E&M codes based on corresponding expected time:
Initial Hospital Care99221 30, 99222 50, 99223 70
Subsequent Hospital Care99231 15, 99232 25, 99233 35
Inpatient Consultations99251 20, 99252 40, 99253 55, 99254 80, 99255 110
Component Based E&M CodingThree Elements:
HistoryChief ComplaintHistory of Present Illness (HPI)Review of Systems (ROS)Past Medical, Family, Social History (PFSH)
Examination
Medical Decision-Making (MDM)Number of diagnoses or management optionsAmount and/or complexity of data reviewed or orderedRisk of complications and/or morbidity or mortality
History• HPI is either brief (1-3 elements) or extended (4 elements or 3 chronic
problems)• Select the level of the LOWEST element: • So Extended HPI, 10 system ROS, but no PFSH codes as expanded problem
focused
Level of History HPI ROS PFSHProblem Focused Brief None NoneExpanded Problem Focused
Brief 1 system None
Detailed Extended 2 – 9 systems 1pertinent PFSH
Comprehensive Extended 10 or more systems Complete PFSH
Exam• Problem focused exam – a limited exam of the affected body area or organ
system.• Expanded problem focused exam – a limited exam of the affected body area
or organ system and any other symptomatic or related body area(s) or organ system(s).
• Detailed exam – an extended exam of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s).
• Comprehensive exam – a general multisystem exam, or a complete exam of a single organ system and other symptomatic or related body area(s) or organ system(s).
Medical Decisionmaking
Number of diagnoses or management options
Amount and/or complexity of data to be reviewed
Risk of complications and/or morbidity or mortality
Level of Complexity of Medical Decision Making
Minimal Minimal or None Minimal STRAIGHTFORWARD
Limited Limited Low LOW COMPLEXITY
Multiple Moderate Moderate MODERATE COMPLEXITY
Extensive Extensive High HIGH COMPLEXITY
Table of RiskMinimal Risk
Risk Level Presenting Problems
Diagnostic Procedures
Management Options Selected
Minimal Risk · One self-limited or minor problem, e.g., cold, insect bite, tinea corporis
Laboratory tests Rest
Chest X-rays GarglesRequires ONE o
f these elements in ANY of the three categories listed
EKG/EEG Elastic bandages
Urinalysis Superficial dressings
Ultrasound/EchocardiogramKOH prep
Low RiskRisk Level Presenting Problems Diagnostic Procedures Management Options
SelectedLow Risk Two or more self-limited or
minor problemsPhysiologic tests not under stress, e.g., PFTs Over the counter drugs
One stable chronic illness, e.g., well controlled HTN , DM2, cataract
Non-cardiovascular imaging studies with contrast, e.g., barium enema
Minor surgery, with no identified risk factors
Requires ONE of these elements in ANY of the three categories listed
Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain
Superficial needle biopsy Physical therapy
ABG Occupational therapy
Skin biopsies IV fluids, without additives
Moderate RiskRisk Level Presenting Problems Diagnostic Procedures Management Options
SelectedModerate Risk
Two stable chronic illnesses
Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test
Minor surgery, with identified risk factors
One chronic illness with mild exacerbation or progression
Diagnostic endoscopies, with no identified risk factors
Elective major surgery (open, percutaneous, or endoscopic), with no identified risk factors
Requires ONE of these elements in ANY of the three categories listed
Undiagnosed new problem with uncertain prognosis (e.g., lump in breast)
Deep needle, or incisional biopsies
Prescription drug management
Acute complicated injury, e.g., head injury, with brief loss of consciousness
Cardiovascular imaging studies, with contrast, with no identified risk factors, e.g., arteriogram, cardiac catheterization
Therapeutic nuclear medicine
Obtain fluid from body cavity, e.g., LP/thoracentesis IV fluids, with additives
Closed treatment of fracture or dislocation, without manipulation
High RiskRisk Level Presenting Problems Diagnostic Procedures Management Options Selected
High Risk One or more chronic illness, with severe exacerbation or progression
Cardiovascular imaging, with contrast, with identified risk factors
Elective major surgery (open, percutaneous, endoscopic), with identified risk factors
Acute or chronic illness or injury, which poses a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness, with potential threat to self or others, peritonitis, ARF
Cardiac EP studiesEmergency major surgery (open, percutaneous, endoscopic)
Requires ONE of these elements in ANY of the three categories listed
Diagnostic endoscopies, with identified risk factors
Parenteral controlled substances
An abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory loss
DiscographyDrug therapy requiring intensive monitoring for toxicity
History, exam, and medical decision-making must meet or exceed the same level in order to assign a specific code
Initial visit
Subsequent visitTwo out of 3 components of history, exam, and medical decision-making must meet or exceed the same level to assign a code (1 of the 2 has to be medical decision-making)
Observation or Inpatient, same day discharge
Observation > 1 day• Billed only by the physician who admitted the patient to observation and was
responsible for the patient during his/her stay.• All other providers should bill the outpatient E/M codes that describe their
participation in the patient’s care (i.e., office and other outpatient service codes or outpatient consultation codes)
• History, exam, and medical decision-making must meet or exceed the same level in order to assign a specific code
Observation date of discharge• Bill only if patient stays >1 day in observation status• If admitted, use inpatient codes• On date of discharge, can bill 99217, which requires documentation of:
Final patient examDiscussion of the hospital stayInstructions for continuing carePreparation of discharge records, prescriptions, and referral forms
Surgical Billing• Most services organized around the Global Service Fee• Fee is based on the procedure or procedures to be done• Billed by the surgeon, even if elements performed by other providers
What is includedPreoperative visits (1 day before major surgery and the day of minor surgery);Intraoperative services that are normally a usual and necessary part of a surgical procedure;Complications after surgery that do not require additional trips to the operating room (medical and surgical services only);Postoperative visits during the postoperative period of the surgery (zero, 10 or 90 days) that are related to recovery from the surgery;Supplies used that are related to the surgery;Miscellaneous items used during the surgical procedure that are related to the surgery, such as dressing changes, local incisional care, removal of operative pack and removal of sutures, staples, lines, wires, tubes or drains.
What is excludedInitial consultation or evaluation to determine the need for major surgery (modifier 57);Services of other physicians, except when the surgeon and the other physician or physicians agree on transferring patient care outside the group practice (agreement may be in the form of a letter or an annotation in the discharge summary, hospital record or ASC record);Visits unrelated to the diagnosis for which the surgical procedure is performed (modifier 24);Treatment for the underlying condition or an added course of treatment that is not part of normal recovery from surgeryDiagnostic tests not normally a part of the surgical procedure;Unrelated surgical procedures during the postoperative period that are not reoperations or treatment for complications (modifier 79);Treatment for postoperative complications that requires a return trip to the operating room (modifier 78);If a less extensive procedure fails and a more extensive procedure is required, the second procedure is payable separately
Emergency Medicine• Subtle distinctions based on location/facility type beyond the realm of this
talk• Pediatric level of risk is not well established- most pediatric specific EDs have
developed their own Levels 99281 99282 99283 99284 99285
History Problem-focused Expanded problem-focused
Expanded problem-focused Detailed Comprehensive
Exam Problem-focused Expanded problem-focused
Expanded problem-focused Detailed Comprehensive
MDM Straightforward Low complexity (Low) moderate complexity
(High) moderate complexity High complexity
Nature of Presenting Problem
Self-limited or minor problem
low to moderate severity Moderate severity
High severity not posing an immediate
significant threat to life or physiological
function
High severity with immediate threat to life
or physiological function
Clinical Examples
Simple suture removal
Minor traumatic injury of an extremity with
localized pain, swelling, and bruising
(no imaging done)
Minor head injury without loss of consciousness,
altered mental status or amnesia
Asthma with >1 neb and/or X-ray/labs
Chest pain with cardiac work up (EKG, X-ray/CT, labs); admit
or discharge
Uncomplicated laceration repairs
Red, swollen cystic lesion on back
Asthma clearing with 1 nebulizer
DVT work-up (leg pain)
Abdominal pain or kidney stone work-up
and treatment that includes CT or
ultrasound, IV fluids, IV/IM meds for pain
Uncomplicated insect bites
Rashes exposure to poison ivy
Extremity trauma with X-ray
Vaginal bleeding, testicular pain
Most completed strokes, TIAs
Visual disturbance with history of foreign
body in eye
Migraine or low back pain with IV/IM and re-
assessmentGreater than single extremity or organ
system trauma
Outpatient
Initial Visit• New patient- someone who has never been seen by you or a physician in the
same specialty in your group • OR who has not been seen in at least three years• Each level requires 3 out of 3 key elements to be met
Level E/M Code History Physical Exam MDM Time
1 99201 Problem Focused
Problem Focused Straightforward 10
2 99202 EPF EPF Straightforward 20
3 99203 Detailed Detailed Low 30
4 99204 Comprehensive Comprehensive Moderate 45
5 99205 Comprehensive Comprehensive High 60
Established patientsOnly requires 2 of 3 elements to code a given level
Level E/M Code History Physical Exam MDM Time
1 99211 None None None 5
2 99212 Problem Focused Problem Focused Straightforward 10
3 99213 EPF EPF Low 15
4 99214 Detailed Detailed Moderate 25
5 99215 Comprehensive Comprehensive High 40
Pitfalls• Consults- Medicare and many Medicaid plans no longer reimburse• Bill out as inpatient subsequent or new office visit• Still need to document who requested, what your recommendations are, send
letter (outpatient) or note in chart (inpatient)• For the billionth time- physician cosignature or attestation is not sufficient for
physician to bill• Time based billing is for face to face• Student billing- currently different rules for MD student vs APP• 2020 Fee schedule proposes to change this
Questions? Comments? Cases?