Write to The Editor, AAOSBulletin, 6300 North River Road, Rosemont, Ill. 60018-4262
This is in reference to Jeri Harris' article (Coding Corner column, June 1998 Bulletin,) in which she notes that "the services of a registered nurse or a physician's [sic] assistant are included in the primary surgeon's payment. " This is not correct. A PA-C, or certified physician assistant can be paid for his or her surgical assistance. Also, a nurse practitioner can be paid.
Michael J. Fay, MD
Response: My research involved polling 50 carriers on their prospective payment policy, only a small percentage actually allow and pay for surgical assist fees for either certified surgical nurse or physician assistants. The payer prospective reasoning is that the facility charges include nurses and support staff in relation to surgical procedures.
When the surgeon determines he wants to pay for extra staffing (physician assistant or certified surgical nurse) to assist in surgery, that is considered by the insurance industry under the "incident to" act. If a qualified surgical assistant need is apparent, then another MD physician can assist. However, the carrier may not reimburse the MD for surgical assistant if the carrier deems that it was not medically necessary.
Most carriers require that the physician assistant or certified surgical nurse be credentialed as a provider of service with each carrier prior to billing for services. Additionally, the pre-authorization should be done in advance to ensure the carrier allows coverage for those services under the patient's medical benefit plan.
Some carriers do acknowledge the use of HCPCS modifiers to denote that a physician's assistant, nurse practitioner or clinical nurse specialist was involved. However, most won't retroactively pay prior to credentialing or pre-authorization.
Jeri Harris, CPC, CPC-H
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