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March 2010
AAPA brief -
Read more here
Aetna reimbursement change
for mid-level practitioners
Beginning with June 1, 2010
dates of service, Aetna will pay mid-level practitioners at
85 percent* of the contracted rates for covered professional
services (consistent with the Centers for Medicare and
Medicaid Services payment policy).
This policy applies to
nurse practitioners, physician assistants, certified nurse
midwives and registered nurses. As of June 1, you will need
to list the mid-level practitioner's name in the servicing
provider field when you submit claims for services rendered
by a mid-level practitioner.
This policy does not apply
to:
- Certified registered
nurse anesthetists, registered nurse first assistants or
behavioral health practitioners
- Claims billed with an
assistant surgery modifier
- Covered DME,
orthotics, prosthetics, supplies, drugs, laboratory,
radiology services and immunizations billed by a
mid-level practitioner
- Medicare Private
Fee-for-Service (non-network based)
- Providers contracted
through a third party or vendor
Also, we want to make sure
the names of all your practices' mid-level practitioners
display in our directories. For information on joining our
network, reference
www.aetna.com. For other questions including the process
for submitting practitioner contact information, contact
your network representative.
* This policy will not apply in the states of Alaska,
Kansas, Maine and Missouri.
From:
http://www.aetna.com/provider/data/OLU_MA_MAR2010_fin.pdf
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November 13, 2009
Medicare Eliminates Consultation Codes |
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Consultation Codes are being eliminated
from the Medicare
program, except for Telehealth
services, effective January 1, 2010. Instead, initial
and subsequent visit codes will be used in the hospital
and nursing facility. New and established patient codes
will be used in the office/clinic setting. The RVUs are
being increased for the initial visit/new patient codes
and subsequent visit/established patient visit codes in
all settings.
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Consultation codes, in any setting, were previously
not eligible for shared/split visit billing.
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In the hospital, an initial and subsequent hospital
visit may be billed as a shared visit under the
physician's NPI, with reimbursement at 100%, if all
the requirements for a
shared visit are met.
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In the office, only established patient visits are
eligible for shared visit billing. This rule has not
changed. Of course, the
incident-to rule still applies in the office
setting as well.
CPT©
2010 will continue to list the Consultation Codes. The
private payers will continue to utilize the Consultation
codes. AAPA will begin to query private payers to obtain
information on their long-term plan for the use of
consultation codes. This new rule applies to Medicare
consultations only.
The new rule was published in the Federal Register
November
25, 2009.
From
the American Academy of Physician Assistants -
http://www.aapa.org/advocacy-and-practice-resources/reimbursement
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Billing for First Assisting at Surgery
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Medicare covers PAs for first assisting at surgery at 85
percent of the physician fee schedule or 13.6 percent of the
primary surgeon's fee for the surgery (85 percent of the
physician first assistant rate, 16 percent). PAs can provide
the same range of first assistant services as physicians. A
claim for first assisting at surgery should be submitted
with the PA's NPI number (or PIN) and the "AS" modifier
appended to the surgical code.
PAs should be aware of the Medicare
list of approximately 1,900 CPT codesfor
which a first assistant at surgery will not be reimbursed.
These code restrictions apply to all providers covered for
first assisting at surgery under Medicare.
PAs First Assisting in Teaching Hospitals
Medicare restricts coverage for PAs (or physicians) who
first assist in a teaching hospital that has a graduate
education program in the fields of medicine, osteopathy,
dentistry, or podiatry and is approved by the appropriate
accrediting body for graduate education. In general, no
reimbursement payment is made for first assisting at surgery
when it is provided in a teaching hospital that has a
training program related to the medical specialty required
for the particular surgical procedure and has a qualified
resident available to perform the service. Hospitals that
only participate in the approved programs of other
hospitals, or that have non-approved programs are not
subject to these restrictions.
However, if these teaching hospitals have no "qualified"
resident available, in trauma cases, or if the primary
surgeon has an across-the-board policy of never involving
residents in the preoperative, operative, or postoperative
care of his or her patients, Medicare will cover the
services of a PA first assistant. The exact criteria that
determine a "qualified" resident are somewhat vague. Some
Medicare carriers have said that the primary surgeon can
make that judgment. The surgeon may believe that an
available resident who has been on duty for an extended
period of time may not be the best pair of hands to use in a
particular operation. However, to use a PA or a physician
for the first-assist duties because a qualified resident is
making rounds in another part of the hospital, for example,
would probably not be appropriate.
The Medicare carrier may require that the first-assist claim
be accompanied by a certificate that reads as follows:
"I understand that section 1842(b)(6)(D) of the Social
Security Act generally prohibits Medicare Part B...payment
for services of assistants at surgery in teaching hospitals
when qualified residents are available to furnish such
services. I certify that the services for which payment is
claimed were medically necessary, and that no qualified
resident was available to perform the services. I further
understand that these services are subject to post-payment
review by the Medicare carrier."
Check with your local Medicare carrier regarding this
requirement.
Information taken from the AAPA -
http://www.aapa.org/advocacy-and-practice-resources/reimbursement/medicare/892-first-assisting-at-surgery
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INC • PO Box 10781 • Glendale AZ 85318-0781
800-804-7267 • Fax (623) 581-0085 •
Email
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