Home  |   Subscribe  |   Resources  |   Reprints  |   Writers' Guidelines

August 2019

Chart Conundrums: Be Mindful of PA Documentation
By Kelly Long, CPC
For The Record
Vol. 31 No. 7 P. 26

Physician assistants (PAs) are nationally certified and state-licensed medical professionals who play an integral role in health care delivery. According to the 2018 annual report of the National Commission on Certification of Physician Assistants, there are more than 130,000 certified PAs spread out over every area of medicine.

In hospitals, outpatient clinics, and physician practices, PAs can be found taking patient medical histories, conducting physical exams, ordering and performing diagnostic and therapeutic procedures, providing working diagnoses, developing treatment plans, monitoring a patient’s health throughout treatment, assisting during surgery, offering patient counseling and education, and making referrals as necessary.

Although each state has variations in licensing requirements, in general PAs cannot practice beyond their current level of education and expertise. To satisfy the requirements mandated by the Centers for Medicare & Medicaid Services (CMS), every PA must work with a physician supervisor responsible for the overall direction and management of the work performed by the PA. The physician supervisor is also responsible for ensuring that services ordered and provided by the PA are medically necessary.

Although they do not need to be physically present when the PA provides patient care, the physician must be immediately available in case the PA encounters any issues or questions that cannot be resolved alone.

PAs are reimbursed under strict guidelines established by Medicare, Medicaid, TRICARE, and commercial payers, making it critical that coding and billing of PA services be accurate, complete, and compliant. Over the past year, numerous high-profile lawsuits involving billing of PA services have been brought against provider organizations for violations of the False Claims Act. Many of these suits have been filed by internal whistleblowers who receive financial rewards for bringing the fraud to light (see sidebar).

Accurate and Compliant PA Reimbursement
PAs may submit Medicare claims using their national provider identifier (NPI). As a result, practices employing PAs may directly bill insurance companies even when the physician supervisor is off-site or has not provided any input toward the patient’s care plan.

However, CMS does not allow PAs to “direct bill” as care providers. Any Medicare reimbursements are made directly to the PA’s employer and are reimbursed at 85%. Special provisions are made for “Incident-to” and “Shared visits” billing, which can be reimbursed at 100% based on the following criteria.

Incident-to Billing
Under CMS guidelines, “incident-to” billing is available for essential services that a patient receives from both a physician and a PA. These services must occur in an office or clinic setting on the same calendar day.

During the initial visit, the physician must personally treat the patient for their medical problem and establish a diagnosis and treatment plan. The PA must perform some part of the service incidentally in a face-to-face encounter with the patient during the development of the diagnosis and/or treatment plan.

To satisfy CMS documentation requirements, there must be a medical note that details all of the professional services provided, clearly designating the work of the physician in relation to the work of the PA. Incident-to billing does not apply to commercial payers unless specified in their policy.

Shared Visit Billing
CMS also allows physicians and PAs employed by the same physician group to “split” or “share” reimbursement for coordinated services in specific circumstances.

“Shared visits” must occur in hospital-owned inpatient and outpatient facilities or offices that strictly follow state guidelines for PA supervision. In these settings, claims may be submitted under the appropriate physician, allowing the physician and the PA to “share” the encounter. The practice will receive 100% reimbursement via the physician reimbursement rate rather than the standard 85% reimbursement rate for PA services.

Shared visits can be billed only as such for evaluation and management (E/M) care, meaning that procedural and critical care performed in tandem by a physician and a PA do not qualify for the extra 15% reimbursement. The key to shared visit billing is clear documentation that meets the requirements for both parties to bill for care. When documenting care provided, each practitioner must follow the split/share guidelines closely to substantiate these claims.

Commercial insurers set their own guidelines for PA billing, which may differ from CMS policies. Many commercial insurers choose not to enroll PAs with NPIs or the equivalent. Instead, they instruct PAs to bill using their supervising physician’s NPI.

PAs and the EHR
The work of PAs—and compliant coding and billing of this work—depends a great deal on the reliability of EHRs that safeguard PA documentation and distinguish it from the documentation of other providers. EHRs should be designed to correctly capture and quantify the patient care contributions of PAs. For example, a well-designed EHR allows PAs to automatically notify their supervising physicians when a cosignature is needed. In addition, the technology allows physicians to easily cosign records.

Another essential EHR feature is the ability to track patient care without overriding the PA’s name when a physician signature is required. To ensure full transparency, methods that measure the contribution of services provided by PAs should be fully incorporated within the EHR. When multiple health care professionals are contributing to the patient record, all signatures must be retained so that each person’s contributions are clearly denoted.

Some EHR systems allow a variety of users to contribute text to the same progress note or flow sheet. If an EHR system does not allow multiple providers to document and sign, however, it may be difficult if not impossible to verify and distinguish between work performed by the physician, the PA, and any other providers involved in patient care.

According to the American Academy of Physician Assistants, EHRs should incorporate specific safeguards for PA documentation: “The Office of Inspector General recommends EHR safeguards to avoid fraud, which include user logs and controls to validate claims with rendering provider profiles to avoid submission of false claims by physicians when PAs are involved in shared care but physician participation or supporting documentation is missing. EHRs also need to safeguard against the ability to change the authorship of a document to ensure an accurate medical-legal document and prohibit fraud, and a physician should not have the ability to edit a PA’s note as they would be able to do for a resident or fellow.”

Mitigate Compliance Risk
As noted, CMS does allow PAs to bill using a physician’s NPI number at 100% of the physician rate fee under special circumstances. However, incident-to billing can be misunderstood and misused, leading to accusations of fraudulent claims and reimbursement requests.

Recently, incident-to billing has been under significant scrutiny by the Office of Inspector General and state agencies. In the event of an audit, each practice must ensure that their incident-to billing is correctly documented and submitted to avoid potential financial and compliance risk.

The controversy surrounding fraud and PAs arises when a practice or a physician allows a PA to treat patients but then submits claims that suggest all treatment was provided by a medical doctor. In these cases, rather than upcoding the E/M level as instructed, a practice or a physician is “upcoding the provider” to receive the 100% physician reimbursement rate instead of the 85% PA rate for non-E/M services. By Medicare, Medicaid, and TRICARE guidelines, this type of falsified coding is considered fraud.

PAs play an essential role in today’s health care environment. Provider organizations increasingly depend on these professionals for their contribution to patient care, cost reduction initiatives, and quality improvement processes. When it comes to compliant coding and billing of PA services, the best way to ensure coding integrity and thus mitigate compliance issues and the risk of fraud is to integrate a culture of complete and accurate documentation that clearly delineates each provider’s contributions to and participation in patient care.

— Kelly Long, CPC, is an ambulatory coding analyst at 3M Health Information Systems.


With help from whistleblowers, federal authorities have stepped up their efforts to combat violations of the False Claims Act. The following are notable cases from the past year:

• A large dermatology practice in New York State agreed to pay more than $800,000 to settle claims that it overcharged Medicaid, Medicare, and TRICARE by falsely submitting claims under physicians’ names in violation of both the federal and New York State False Claims acts.

A whistleblower complaint revealed that many of the physicians named on invoices were not in the office the day care was provided and could not have supervised in the rendering of services, and that some of the nonphysician practitioners who provided care were not licensed to do so in the state of New York.

• A second New York physician practice self-disclosed problematic conduct to the Office of Inspector General (OIG) and agreed to pay more than $20,000 for violating the Civil Monetary Penalties Law. The OIG alleged the practice submitted claims to Medicare and TRICARE for incident-to services provided by a physician assistant (PA) under a physician’s national provider identifier when Medicare and TRICARE supervision requirements had not been met.

• Two East Coast urgent care centers agreed to pay $2 million to settle a lawsuit filed by a former employee claiming violation of the False Claims Act. The lawsuit alleges the centers falsely inflated the level of services provided and failed to identify service providers in claims submitted to Medicare and several state Medicaid agencies. For filing the suit, the former employee will receive a 17% relator’s share.

• Two pain management clinics in northern Virginia will pay $3.3 million to resolve a False Claims Act case filed by a former PA employee. The whistleblower alleges the clinics billed services provided by PAs and nurse practitioners as if they were provided by a physician.

In addition, the suit claims the clinics ordered medically unnecessary tests and submitted claims for urine drug testing that did not comply with the Stark Law and/or Anti-Kickback Statute.

— KL