Home Letters Billing midlevel consults

Billing midlevel consults

August 2009

Published in the August 2009 issue of Today’s Hospitalist

The “By the Numbers” coding columns in the June and July 2009 issues of Today’s Hospitalist contain problematic statements about the role of PAs in performing “and billing for “consultations.

The article in the June issue states that “midlevels may be the provider of record requesting a consult, but according to CPT guidelines, the consultant must be a physician.” That is incorrect. CPT guidelines do not prohibit PAs from performing a consultation.

There is widespread confusion about this issue, in part because the CPT manual was created by and for physicians. Some have interpreted the use of the term “physician” within certain code descriptors as evidence that only physicians are authorized to use certain codes. The AMA, which owns the CPT system, has taken several steps to counter that perception.

Medicare has also clearly stated that PAs may perform consultations in any practice setting. The Medicare Carriers Manual Transmittal 1725 (Sept. 27, 2001) states: “Non-physician practitioners, e.g., nurse practitioners, certified nurse mid-wives or physician assistants, may request a consultation. They may also perform other medically necessary services, e.g., consultations, when the performance is within the scope of practice for that type of non-physician practitioner in the State in which they practice.”

Note that PAs and NPs are reimbursed by Medicare at 85% of the physician amount for their performance of a consult. Generally, the professional who provides the majority of the service should bill Medicare. (Some private payers will cover a consult performed by a PA or an NP at the physician rate.)

Further, visits following a consultation are often subsequent hospital visits, which can be shared by PAs or NPs with physicians. Those payments can be at the full physician rate, if Medicare’s shared-visit requirements are met. Regarding the July column, the author states that consults can’t be billed as a shared service. While that is correct, I take issue with the following sentence: “You may want to consider having only the MDs work on consults.”

This assumes that physicians are not already fully engaged treating the most critically ill patients and that they should perform consults that have been successfully handled by PAs.

I believe that PAs and NPs, working with physicians and in accordance with state law and hospital policy, should be encouraged to deliver the appropriate level of care, to the full extent of their education, skill and training. The patient’s acuity level and the health care professional’s expertise should determine who provides the care. While reimbursement is important, it should not be the primary driver of how professionals are utilized.

Michael Powe

Alexandria, Va.

The author is vice president of health systems & reimbursement policy for the American Academy of Physician Assistants. He can be reached at michael@aapa.org. More information on shared-visit billing is online.