Podcast Episode 4: Physician Extender Coding

Episode Summary: Physician extenders (physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives) can ease the burden of the physician shortage. Coding and billing for utilizing physician extenders in a medical practice can increase reimbursement, but only in certain situations. Hosts Neal Sheth and Dr. Piyush Sheth explore the nuances of using physician extenders.

Don’t forget to subscribe to this podcast. 

Hosts: Neal Sheth, CGSC; Piyush Sheth, MD, FACS, DABS, CGSC

How can the complexities of medical coding be simplified? Can healthcare providers and professional medical coders maintain efficiency in an environment of ever-increasing complexity? This is Unraveling Medical Coding.

NEAL SHETH: There is a physician shortage in the U.S. As a consequence, the use of physician extenders has become commonplace. What are physician extenders?

PIYUSH SHETH: A physician extender, or non-physician practitioner, is a licensed health care provider, who is not a physician, that provides medical services typically performed by a physician. The term physician extender is used for physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives.

Since there is a physician shortage that is expected to worsen, using physician extenders can help. They can provide healthcare services on their own or under the supervision of a physician.

When a physician bills for services, they are paid at 100% of Medicare Physician Fee Schedule. When physician extenders bill for services, they are paid at 85% of the Medicare Physician Fee Schedule.

In certain circumstances, if physician extender provides services under the supervision of a physician, the physician can bill for the service and get paid at 100% of the Medicare Physician Fee Schedule.

NEAL: In the coding domain, the term “incident to” is bantered about. What exactly does this refer to?

PIYUSH: “Incident to” services are services that are an integral, although incidental, part of a physician's professional services provided in the physician's office or in the patient's home. These services are part of a patient's normal course of treatment during which a physician personally performs an initial service, determines a plan of care, and remains actively involved in the ongoing course of treatment. A physician extender can provide subsequent services for the predetermined plan of care as long as that plan of care does not change. The physician would be able to bill for those subsequent services. If the patient has a new or worsening complaint, the physician must conduct a new evaluation and management service for that complaint and update the plan of care. All initial and subsequent services under “incident to” billing would be paid to the physician at 100% of the Medicare Physician Fee Schedule.

You don’t have to use “incident to” services when utilizing physician extenders. The physician extender can independently provide the initial and all subsequent visit care. These would then be paid at 85% of the Medicare Physician Fee Schedule.

NEAL: So, the benefit to billing under “incident to” services is that reimbursement is better.

PIYUSH: Correct. There are a few caveats however.

First, the physician must be physically present in the office and immediately available to provide assistance and direction to the physician extender.

Second, the physician extender must be employed by the physician or the physician’s group.

And third, the physician extender can only provide services within their scope of practice.

NEAL: Well, what about using physician extenders in hospital or ER settings?

PIYUSH: That would be called “shared/split” services. A shared/split service occurs when both a physician and physician extender provide a face-to-face service on the same patient, on the same date of service. If each documents a ‘substantive portion’ of the service, the work of the physician and physician extender can be combined into a single billed service. Again, the benefit is that reimbursement would be better.

NEAL: How is “substantive portion” of an evaluation and management service defined?

PIYUSH: The definition is actually quite vague. It is defined as “all or some portion of the history, exam, or medical decision making.” Technically, as long as you document some sort of face-to-face service with any portion of history, physical exam, or medical decision making, you can “hijack” a physician extenders documentation and use it in addition to your documentation to receive payment at 100% of the Medicare Physician Fee Schedule.

NEAL: Hijack is a pretty strong word.

PIYUSH: I know but let’s say that a physician extender documents a comprehensive history, comprehensive physical exam, and high medical decision making and the physician documents something simple such as, “patient was seen and examined, abdomen was distended and tender diffusely, will proceed to surgery.” Technically, both notes can be combined and billed under the physician using the highest-level evaluation and management CPT code and receive 100% of the Medicare Physician Fee Schedule payment. I’m a little old fashioned and I feel guilty documenting so little. In my clinical practice, I tend to document significantly more.

NEAL: I’m sure there are caveats to shared/split billing.

PIYUSH: You’re absolutely right.

Caveat 1: The physician must provide a face-to-face service.

If the physician only reviews the physician extenders’ note, or if the physician simply documents “seen and agree”, or if the physician simply co-signs the physician extender’s note, then the physician extender would bill for the service since there is not sufficient documentation to support a face-to-face service.

An example of acceptable documentation by the physician would be as follows:

 “I personally saw and examined the patient and discussed the management with the physician extender. I reviewed the physician extender’s note and agree with the documented findings and plan of care with the following changes [insert any corrections here]. The portions of the history, exam, and/or medical decision making that I performed are as follows [insert your documentation].”

Caveat 2: Shared / split services cannot be used for consultation services, critical care services, or procedural services.

NEAL: So, the take home message is that physician extenders can allow you to see more patients and bill for higher reimbursement if certain requirements are met.

PIYUSH: You got it!

NEAL: Thanks for clarifying coding when using physician extenders.

PIYUSH: My pleasure.

NEAL: We hope you enjoyed this episode of Unraveling Medical Coding. Don’t forget to subscribe to Unraveling Medical Coding from wherever you get your podcasts. Also, please leave us a review on Apple podcasts. Stay safe, and stay healthy.