Coding Cues

August 17, 2007

Answers to your questions about..E&M visits during prenatal care; PA services

Key Points

E&M visits during prenatal care

I'm an FP, but I also handle obstetrical cases. E&M claims that I submit for services other than a prenatal visit, like for a URI, are being rejected because they fall within the maternity care global period. Is there something I can do to get paid for those other services?

Yes, there are various ways to get reimbursed for the services you provide your OB patients outside the scope of their pregnancies. And how you handle the claims will depend on the insurer.

Some insurers may want modifier –24 (unrelated E&M service . . .) or modifier –79 (unrelated procedure or service . . .) attached to the E&M service. Again, list the acute diagnosis first.

If you perform a procedure, you may need to add modifier –79 to the procedure code and modifier –25 (significant, separately identifiable E&M service . . .) to the E&M code. List the diagnosis in the same order as the CPT codes.

Ask your insurers what they require.

PA services

Our busy practice wants to hire a physician assistant, but we're confused about the kinds of services a PA can perform and if she has to obtain a provider number in order to see patients. Can you clarify this?

Your state governs the scope of services that a physician extender, like a PA or NP, may render. State-by-state summaries of these laws pertaining to PAs are available at the website of the American Academy of Physician Assistants ( http://www.aapa.org/gandp/statelaw.html). Reimbursement depends upon whether you'll bill the service "incident to," using the supervising physician's provider number, or independently, using the PA's own provider number. If you bill Medicare using the PA's number, you'll receive 85 percent of your reimbursement. You'll receive 100 percent when you bill the services incident to. But if you bill incident to, the PA can't see any patients for new problems, and the medical record must clearly document the plan of care the PA is participating in. An independently licensed and credentialed PA, however, may see new and established patients for new problems, and bill under her own number.

Quality reporting initiative

My colleagues and I are confused about CMS' Physician Quality Reporting Initiative. We heard that we can receive a bonus if we report quality measures. Is that true? And where can we find out more?

If you report a designated set of quality measures on Medicare claims from July 1 through Dec. 31, you can earn a bonus payment (subject to a cap) of 1.5 percent of allowed charges. You'll receive your bonus payment sometime in the middle of next year.

Visit the CMS website at http://www.cms.hhs.gov/PQRI/31_PQRIToolKit.asp. Here you'll find links to a list of all the quality measures, the MLN Matters article that describes the program's coding and reporting principles, and the 2007 PQRI Code Master that lists all the codes intended for incorporation into billing software. All of these resources are downloadable.

The author, vice president of operations for Reed Medical Systems in Monroe, MI, has more than 30 years' experience as a practice management consultant, as well as being a certified coding specialist, certified compliance officer, and a certified medical assistant.