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Updated Hospital Shared-billing Guidelines:
Medicare and Shared Visits
As of October 25, 2002, new rules championed by AAPA give PAs and their supervising physicians increased latitude in billing for evaluation and management (E/M) services provided in the hospital setting. Responding to concerns expressed by AAPA and other medical specialty groups, the Centers for Medicare and Medicaid Services (CMS) substantially altered its policy involving the coverage of E/M hospital services when provided jointly by a PA and a physician to the same patient.
The new policy, detailed in Medicare Transmittal 1776, allows E/M services provided by a PA and a physician in the hospital (inpatient, outpatient, or in the emergency department) to be combined for billing purposes when delivered to the same patient on the same day. The combined services may be billed under the name and Medicare provider identification number (PIN) of the physician at 100 percent of the fee schedule, as long as the physician provides some portion of the E/M service during a face-to-face encounter with the patient. The policy also requires the physician and PA to work for the same employer, practice, or hospital.
The new policy eliminates the "split billing" requirement. A September 2001 Medicare transmittal required that split billing be used to separately document and bill for E/M services provided by a PA and a physician when both provided care to the same patient on the same day. AAPA alerted CMS officials to the administrative and billing difficulties that this requirement would cause for both health care professionals and Medicare carriers, and a CMS review of the split billing rule was initiated.
Prior to the split billing requirement, Medicare rules for hospital billing required that the health care professional who provided the majority of the professional E/M service to the patient be the one under whose name and number the bill was submitted; if the PA did most of the work for the patient, the service was billed under the PA's name and PIN. The reimbursement was 85 percent of the fee schedule.
The new policy allows PAs and physicians to share visits made to patients with the combined work of both covered at 100 percent of the fee schedule. That is, if the PA provides the majority of the service for the patient and the physician provides any face-to-face portion of the E/M encounter, the entire service may be billed under the physician's name and PIN. The new rule does not extend to procedures or consultations. The practitioner who substantially performs the procedure is the one under whose name and number the procedure should be billed.
Remember: To combine the professional work done by a PA and a physician, the following guidelines must be followed:
- The PA and the physician must work for the same entity.
- The regulation applies only to E/M services and not to procedures.
- The physician must provide some face-to-face portion of the E/M services. Simply reviewing or signing the patient's chart is not sufficient.
- "Incident to" billing has never applied to the hospital setting - and still does not apply.
If the physician is not present for any of the face-to-face portion of the E/M encounter, the service is appropriately billed under the PA's name and Medicare PIN, with reimbursement at the 85 percent rate. When billing for hospital services provided by PAs under the PA's name and PIN, Medicare does not require the on-site presence of the supervising physician; access to telephonic communication is sufficient. Always check with your state law and hospital policies, which may be more restrictive than Medicare's policies.
AAPA has reimbursement specialists on its staff to answer specific questions concerning proper billing for services provided by PAs. If you have a reimbursement problem or question, write to michael@aapa.org or aiwanik@aapa.org.
Last Revised: 2/8/08
