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.

1

2

3

44

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?