O2supply Posted March 17, 2011 Share Posted March 17, 2011 Hi all, A psychiatrist that I am rotating with is interested in having the hospital he works for hire a PA to help do inpatient rounds at the behavioral health hospital and basically cover the medical aspect of the patient care (physical exams and managing medical complaints). He and the other psychiatrist are frustrated with the current medical doctor that visits the hospital. He wants to know how to, if at all possible, allow the PA and him to bill separately as the PA would be doing PEs and he would do the mental exams. He does not want to bill "incident to" or as a shared visit. The PA would see the patient upon initial visit and subequently as need arose. The PA and the doctor would be seeing the same patient the same day at different times. I do not know much about billing and coding, but it seems like the PA would be working outside of the scope of practice if he were considering the psychiatrist his SP. Link to comment Share on other sites More sharing options...
Contrarian Posted March 17, 2011 Share Posted March 17, 2011 If the PA is credentialed with the insurance companies... then the PA could do the "Medicine" and bill at the PA rate... and the Physician can do the "Psych." Two separate and distinct "encounters" on the same day. I do not know much about billing and coding, but it seems like the PA would be working outside of the scope of practice if he were considering the psychiatrist his SP. NOPE...!!! As long as the Psychiatrist was capable of practicing internal medicine (which they are because internal medicine IS in the Psychiatrist "scope of practice.")... then the PA CAN use this Physician as their SP. The only problem here may be that the PA may possess much more current general medicine knowledge than their SP. I know this because I was in this very position a couple yrs ago... I was hired to do the state required PEs on all the admissions to a pair of inpatient psych facilities. I also provided acute care to the inpatients of this facility. Some of the Psychiatrists there were excellent Internal Medicine Clinicians... others... not so much. My SP was a Psychiatrist and the State board of Medicine had NO problem with this because everything I was going to do for patients (general internal medicine/acute care stuff) in this facility was within the scope of practice of my Psychiatrist SP. For a couple yrs, I handled EVERYthing but psych issues... and the psychiatrists handled all psych issues but consiously avoided getting involved with medical issues. Later, I completed my UNMC-MPAS focused in Psychiatry, then continued to focus on Internal medicine issues, but would fill in for the Psych Providers in emergencies. Now I do some inpatient & outpatient psychiatry (~30%) and internal medicine (~70%). While the medical specialty of psychiatry utilizes research in the field of neuroscience, psychology, medicine, biology, biochemistry, and pharmacology, it has generally been considered a middle ground between neurology and psychology. Unlike other physicians and neurologists, psychiatrists specialize in the doctor-patient relationship and are trained to varying extents in the use of psychotherapy and other therapeutic communication techniques. Psychiatrists also differ from psychologists in that they are physicians and the entirety of their post-graduate training is revolved around the field of medicine. They complete the same 4 yr medical curriculum as every other allopathic and homeopathic physician which qualifies them to practice general medicine. Psychiatrists can therefore counsel patients, prescribe medication, order laboratory tests, order neuroimaging, and conduct physical examinations. Link to comment Share on other sites More sharing options...
coloradopa Posted March 17, 2011 Share Posted March 17, 2011 Hi all, A psychiatrist that I am rotating with is interested in having the hospital he works for hire a PA to help do inpatient rounds at the behavioral health hospital and basically cover the medical aspect of the patient care (physical exams and managing medical complaints). He and the other psychiatrist are frustrated with the current medical doctor that visits the hospital. He wants to know how to, if at all possible, allow the PA and him to bill separately as the PA would be doing PEs and he would do the mental exams. He does not want to bill "incident to" or as a shared visit. The PA would see the patient upon initial visit and subequently as need arose. The PA and the doctor would be seeing the same patient the same day at different times. I do not know much about billing and coding, but it seems like the PA would be working outside of the scope of practice if he were considering the psychiatrist his SP. It could be done but probably isn't legal. First if all its presumably within the scope of practice for a psychiatrist to supervise you. They are licensed to practice medicine and medical management of a psychiatry patient is something they were trained in. The problem is that you both presumably work for the same entity. Therefor what you are describing is a shared visit. From here: http://www.cms.gov/transmittals/downloads/R1776B3.pdf "Setting.--When a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's UPIN/PIN number." You can't have it both ways. Either they are qualified to supervise you (and then could presumably do the medical practice themselves) or they aren't qualified/don't want to then they can't supervise you. In the old days with consults you could consult someone in your practice that had more/different expertise than you did but again supervision is an issue. Bottom line only one person from a given practice can do an E/M bill on a patient in a given day. This is covered here: 30.6.5 - Physicians in Group Practice (Rev. 1, 10-01-03) Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group. Basically since your scope is derived from the SP, you can't be considered a different specialty. The way around this would be to have one of the hospitalists for example as your SP. Then your specialty would be different. Whether they would go along with this is a different story. Michael Powe at AAPA is a good resource for your billing questions. Link to comment Share on other sites More sharing options...
Contrarian Posted March 17, 2011 Share Posted March 17, 2011 While I agree with the gist of what is posted above this is where WE made the distinction: 30.6.5 - Physicians in Group Practice(Rev. 1, 10-01-03) Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Our Psych providers performed a History and Mental Status Exam then prescribed appropriate Emergency Psych Meds. Our PA-Cs performed the state required History and Complete Physical exam then managed the problems unrelated to Psych. (Derm, CAD, Thyroid, HTN, DM, Lacerations, Tinea, etc.) As far as I know, there has NEVER been a problem with billing using this arrangement because a second provider (the PA-C) in the same specialty (Psychiatry) IS seeing the patient for issues that are separate and distinct from Psychiatry. YMMV Contact CMS and ask them directly instead of relying on tertiary and quaternary interpretations ... :wink: Contrarian Link to comment Share on other sites More sharing options...
coloradopa Posted March 17, 2011 Share Posted March 17, 2011 While I agree with the gist of what is posted above this is where WE made the distinction: Our Psych providers performed a History and Mental Status Exam then prescribed appropriate Emergency Psych Meds. A physical exam is required for every E/M encounter. Although there is a psych specialty exam that requires minimal physical (as opposed to mental) documentation. http://emuniversity.com/PDF/Specialty_Exam_Psychiatric.pdf Our PA-Cs performed the state required History and Complete Physical exam then managed the problems unrelated to Psych. (Derm, CAD, Thyroid, HTN, DM, Lacerations, Tinea, etc.) As far as I know, there has NEVER been a problem with billing using this arrangement because a second provider (the PA-C) in the same specialty (Psychiatry) IS seeing the patient for issues that are separate and distinct from Psychiatry. YMMV Contact CMS and ask them directly instead of relying on tertiary and quaternary interpretations ... :wink: Contrarian The problem with this theory is that you could continue to slice up the patient complaints to have an unlimited number of providers from the same group see the patient. One could see the patient for HTN, one for diabetes, one for tinea etc. All of those should be within the purview of a psychiatrist. Or if they are unable to handle them then they could refer those problems to another specialist (ie someone in a different specialty) such as an internist or endocrinologist. NHIC is a Medicare Administrative Contractor for the Northeast. Here is there interpretation of the unrelated problem: "Visits on the Same Day by Different Physicians In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, contractors do not pay physician B for the second visit. The hospital visit descriptors include the phrase “per day” meaning care for the day. If the physicians are each responsible for a different aspect of the patient’s care, contractors may pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses. There are circumstances where concurrent care may be billed by physicians of the same specialty (see concurrent care in this guide)." Concurrent care is defined here: Necessity "Concurrent care exists where more than one physician renders services more extensive than consultative services during a given period of time. The reasonable and necessary services of each physician rendering concurrent care could be covered where each is required to play an active role in the patient’s treatment, for example, because of the existence of more than one medical condition requiring diverse specialized medical services. In order to determine whether concurrent physicians’ services are appropriate, NHIC must determine the following: • Whether the patient’s condition warrants the services of more than one physician on an attending (rather than consultative) basis, and • Whether the individual services provided by each physician are reasonable and necessary. NHIC will consider the specialties of the physicians as well as the patient’s diagnosis, as concurrent care is usually (although not always) initiated because of the existence of more than one medical condition requiring diverse specialized medical or surgical services. The specialties of the physicians are an indication of the necessity for concurrent services, but the patient’s condition and the inherent reasonableness and necessity of the services, as determined by medical staff, is considered." You can read the whole thing here: http://www.medicarenhic.com/providers/pubs/EvaluationandManagementBilling%20Guide.pdf Concurrent care was devised in the era of consults. It was meant for a specialist to take over care of a specific area such as an endocrinologist taking care of the patients diabetes. It all goes back to the specialty of the physician. Since as a PA your specialty is the same as the supervising physician its hard to make a case for concurrent care. The unrelated care clause was meant to address things that were not present in the initial encounter (mostly for outpatient E/M). To the OP, you have a number of resources here: 1. Call CMS - if you can find someone in CMS that will answer your question then that will work, but good luck with that. 2. Find out your Medicare Administrative Contractor (Someone like NHIC). They should have an E/M guide that may or may not answer your question. They also may have a person that can give your guidance on your particular question. 3. Ask your billing people. They may have guidance, and ultimately they have to be able to put the bill in. I work for a big organization that has compliance specialists that are CMS specialists. Thats where I go for my answers. 4. Michael Powe at AAPA would be considered a definitive source for most PA billing questions. Link to comment Share on other sites More sharing options...
Contrarian Posted March 17, 2011 Share Posted March 17, 2011 A physical exam is required for every E/M encounter. Although there is a psych specialty exam that requires minimal physical (as opposed to mental) documentation.http://emuniversity.com/PDF/Specialty_Exam_Psychiatric.pdf Ha..ha... this is funny and predictable...:heheh: Sigh... In typical "expert at everything" fashion... you list a Specialized Psychiatry exam to support your notions but fail to understand that the specialized psychiatry exam DOES NOT include a actual significant Physical exam. Vitals-Yes. Checking for rigidity, cogwheeling and movement disorders-Yes. Actual significant Physical exam NO. The whole idea of this "Specialized" exam is that the "Mental Status Exam" replaces what would normally be a complete Physical exam. Even in the Multi-Axial Assessment, Axis III is suppose to only contain general medical conditions that influence Axis I issues. But of course... those of us who are credentialed in this specialty and do this EVERYDAY couldn't possibly know what we are doing and should defer to the notions of someone who doesn't even work in the specialty. Yeah... ok right... :heheh: Psst... re-read the form YOU linked. Please notice that there really is NO significant physical exam listed aside from constitutional and musculoskeletal. There is NO SHEENT, Cardiac, Lungs, Abd, Genitals, Urinary, Endo, or Neuro listed as part of this "Specialized Psychiatric exam" and if you read the bottom of the form YOU linked, it actually states, " Note: All other body systems not defined on this form are not considered integral parts of a Psychiatric exam." A COMPLETE Comprehensive Specialized Psychiatric Exam includes: HPI Psych HX Legal Hx Drug/Alcohol Hx PMhx Medications Allergies FamilyHx SocialHx Psych Specific ROS (Hallucinations, Illusions, Delusions, Suicidal/Homicidal Ideations, EPS/TD specific movement disorders) Vitals MENTAL STATUS EXAM (Looks, Acts, Feels, Thinks, Speech... Judgement, Affect, Memory, Cognition, Orientation) Multi-Axial Assessment Plan In this specialized Psychiatry exam...there is no palpation, aulscultation, percussion and the provider likely wouldn't even have a stethescope. A Complete History & Physical Exam includes: CC HPI PMhx Medications Allergies FamilyHx SocialHx Complete ROS Vitals Complete head to toe Physical EXAM Assesment Plan IPPA and Stethescope required... To the OP... ask the billing experts who bill DAILY for the specialty you are considering. As I stated above. Our Organization had been billing in this manner for atleast 10 yrs without any problems, issues or concerns and as far as I know, still does. YMMV Contrarian Link to comment Share on other sites More sharing options...
coloradopa Posted March 17, 2011 Share Posted March 17, 2011 Ha..ha... this is funny and predictable...:heheh: Sigh... In typical "expert at everthing" fashion... you list a Specialized Psychiatry exam to support your notions but fail to understand that the specialized psychiatry DOES NOT include a actual significant Physical exam. Vitals-Yes. Checking for rigidity, cogwheeling and movement disorders-Yes. Actual significant Physical exam NO. The whole idea of this "Specialized" exam is that the "Mental Status Exam" replaces what would normally be a complete Physical exam. Even in the Multi-Axial Assessment, Axis III is suppose to only contain general medical conditions that influence Axis I issues. But of course... those of us who are credentialed in this specialty and do this EVERYDAY couldn't possibly know what we are doing and should defer to the notions of someone who doesn't even work in the specialty. Yeah... ok right... :heheh: Psst... re-read the form YOU linked. Please notice that there really is NO significant physical exam listed aside from constitutional and musculoskeletal. There is NO SHEENT, Cardiac, Lungs, Abd, Genitals, Urinary, Endo, or Neuro listed as part of this "Specialized Psychiatric exam" and if you read the bottom of the form YOU linked, it actually states, " A COMPLETE Comprehensive Specialized Psychiatric Exam includes: In this specialized Psychiatry exam...there is no palpation, aulscultation, percussion and the provider likely wouldn't even have a stethescope. A Complete History & Physical Exam includes: IPPA and Stethescope required... To the OP... ask the billing experts who bill DAILY for the specialty you are considering. As I stated above. Our Organization had been billing in this manner for atleast 10 yrs without any problems, issues or concerns and as far as I know, still does. YMMV Contrarian Rereading this I would agree with you for the most part. Based on what I read, Medicare considers what you call a "mental status exam" to be part of the dedicated PE. My mistake is not recognizing it in the context of HPI, PE, A/P which constitutes a billable medical record. If the OP is comfortable billing for this thats their business. The biller is not the one that goes to jail for Medicare fraud. For what its worth the unit I did my psych rotation on had the exact set up that the OP proposes. The PAs managed the medical issues of the patients but did not bill for the services. Just because someone does it doesn't mean its right, it just means they haven't been audited. On the other hand if you tell me that your arrangement has survived a Medicare audit, then I will bow to your greater wisdom. Link to comment Share on other sites More sharing options...
O2supply Posted March 17, 2011 Author Share Posted March 17, 2011 Thank you both for all the insight you have provided. I will check with the billing dept and the AAPA and see what they think as well. Contrarian, not sure about your employment status for psych, but the MD mentioned he did not want to hire the PA, rather have the hospital employ the PA. He works independently and does not want to worry about setting up his hospital-based practice for an employee. Thus the MD and PA would be hired by separate entities. Also, if you don't mind me asking, what billing codes would you use from your aspect? 99222/99232 type codes? Does it matter if they are the same codes the MD uses because those are what he primarily uses? I apologize if my questions regarding billing do not make complete sense. I still have much to learn in that respect! Thanks Link to comment Share on other sites More sharing options...
Contrarian Posted March 18, 2011 Share Posted March 18, 2011 No worries... Since I ALWAYs did my Admission Complete History & Physical Exam AFTER the Psych Provider (MD) completed their admission... I primarily used: Follow-up CPT codes Low level 99231 (example: healthy but psychotic 22 yr old with benign PE and 0 PmHx) Mod level 99232 (~ 25min Follow-up) (Example: simple problems, Tinea, GERD, stable Asthma with benign PE and 0 PmHx) High Level99233 (~ 35min) (example: 50 yr old with DM, Thyroid, etc) EVERY Initial patient encounter (regardless of CPT code used) was ALWAYS documented to meet the requirements for a Level 5 visit... plus I always listed the ICD-9 codes that were applicable. In the job mentioned above... ALL the providers (MD/NP/PA-C) were facility employees. The Physicians were paid a daily rate of $700/day & the Mid-Levels (NPs/PAs) were paid $57/hr. So the facility billed for the Psych Provider's (MD/NP) Admission (99221, 99222, 99223) & the Medical provider's (PA-C)Encounter (99231, 99232, 99233) YMMV... Contrarian Nothing I say here means Jack Schitt!!!!! I am not a licensed coding compliance officer. Even if I was, what I say doesn't matter since I'm not the one paying the billing you submit. Medicare pays your billing, so you have to do what they say. It doesn't matter if I'm right or not. Link to comment Share on other sites More sharing options...
O2supply Posted March 18, 2011 Author Share Posted March 18, 2011 Thanks again, you have been a great help! Link to comment Share on other sites More sharing options...
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