Incorporating Physician Extenders – Billing for PE Services in Neurosurgery Practices

The new restrictions on resident work hours are likely to generate a need for physician extenders to facilitate patient care. Moreover, the shrinking neurosurgical workforce has already stimulated utilization of physician assistants and nurse practitioners-collectively termed physician extenders or PEs-in neurosurgical practices to assist with patient care responsibilities in a variety of settings, including the office and the operating room. This article addresses the appropriate third-party billing methods for PE services that have been incorporated into neurosurgical practices.

Medicare’s Rules Regarding PE Services
Medicare assigns a provider number to an eligible PE; local Medicare carriers can provide eligibility requirements and an application. From Medicare’s perspective, PE services typically fall into two categories: “direct” and “incident-to” services. When a PE provides a service, the claim is filed with the PE’s assigned provider number, and Medicare reimburses the PE at 85 percent of the physician allowable. In contrast, according to the Medicare Carriers Manual Transmittal (MCM) 1764 of Aug. 28, 2002, the PE may perform a service that is incidental to the “direct, personal, professional service furnished by the physician” who initiates the course of treatment. In this circumstance, the claim is filed using the provider number assigned to the physician who is directly supervising the service. Medicare reimburses this service at 100 percent of the physician allowable.

Medicare’s Rules for Surgical Assistance
Although Current Procedural Terminology (CPT) only has modifiers for surgeons assisting at surgery (-80, -81, -82), Medicare created the -AS modifier to identify the surgical assistance of the PE. These services are directly billed under the PE provider number and the modifier -AS is appended to all surgical procedure codes on the claim for which the PE provided surgical assistance. Medicare reimburses the PE at 85 percent of the physician allowable, which is 16 percent of the primary surgeon’s allowable.

Medicare’s Rules for Evaluation & Management Services
Evaluation & Management (E&M) codes in the office or in the hospital may be directly billed by a PE or provided as an “incident-to” service. Further clarification of the billing guidelines described in MCM Transmittal 1764 were published in MCM Transmittal 1776 of Oct. 25, 2002. The accompanying tables summarize the different patient care scenarios utilizing a PE with the appropriate Medicare billing guidelines.

Billing Rules for Other Payers
The billing rules for other payers are not as clear or consistent as Medicare’s. Some non-Medicare payers will credential and assign a provider number to your PE so that services can be directly billed. Other payers require services to be billed “incident to” the supervising physician. Do not assume modifiers -80 (assistant surgeon) or -81 (minimum assistant surgeon) are appropriate for PE surgical assistant services; these modifiers imply physician participation. It is best to obtain individual payer policies in writing as some insurance companies do not allow reimbursement for non-physician provider services.

PEs increasingly are being utilized in neurosurgical practices. Knowing your payers’ billing guidelines will ensure appropriate revenue and reduce the risk for billing errors.

Kim Pollock, MBA, RN, is a consultant with KarenZupko & Associates, a physician practice management and training company based in Chicago. Gregory J. Przybylski, MD, is director of neurosurgery at JFK Medical Center in Edison, N.J. Both are on the faculty for the AANS coding and reimbursement courses.