by Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, COC

A recent article on the news site AXIOS reported on Oregon becoming the first state to allow Physician Assistants to use the title Physician Associate on their license. Other states are expected to follow Oregon’s lead.

The title change, according to the Oregon Society of Physician Associates, “…more accurately reflects our scope of practice (and gives) patients a better understanding of the important credentials and responsibilities that PAs have.” In most states, these responsibilities include the ability to diagnose patients, prescribe medicine, and participate in surgery. Many PAs are a patient’s primary care provider.

The title change will not change how PA services are reimbursed. As coder/billers, it is our responsibility to ensure that the practices that employ PAs and other Non-Physician Practitioners (the preferred term used by CMS) are coding and billing accurately in order to receive appropriate reimbursement for these services. This requires an understanding of the unique requirements that apply.

Here are two essential regulations pertaining to billing for PA and NPP services:

Incident-to
Incident-to is a broad Medicare regulation that allows a physician to bill for services not personally performed but which are part of the physician’s overall care of the patient. There are specific requirements such as no new patients and no new problems, physician presence in the office suite, and employment relationship.

Incident-to is only applicable in the office setting, place of service 11 on CMS-1500 claims.

Split-shared
Split-shared is CMS’s attempt to extend the working relationship between physicians and NPPs from the office setting into the hospital setting.

In order to bill services under the physician, the documentation must indicate that the physician performed the substantive portion of services and took responsibility for the management of the problems addressed.

Billing appropriately for split-shared services can be complicated — CMS made changes to split-shared billing guidelines in 2022, 2023, and 2024. It is essential for coders and billers to stay up to date on these changes.

Other challenges for the coder/biller include:

– Physician misunderstanding of documentation guidelines and confusion with other areas such as teaching physician
– Confusion between office and facility billing (different requirements for different sites of service)
– Confusion in billing for other payers (most are not the same as Medicare)

 

A message from Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, COC
 
I have poured my 25+ years of experience with NPP billing into my new course for Libman Education: CPT®: Billing for Non-Physician Practitioner Services. Whether from assisting a practice before services are billed or cleaning up the results of incorrect billing, my experience can help practices maximize the role of these providers and be paid appropriately for their services – and get to keep the money in case of a payer audit.

 

 

CPT®: Billing for Non-Physician Practitioner Services
Non-Physician Practitioners (NPP) are an increasingly important part of the care team in many organizations. Nationally-recognized coding authority, Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, COC, walks you through what you need to know.
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