Supervision of Physician Assistant, Advanced Nurse Practitioner or Certified Registered Nurse First Assistant

The following modifiers should be used by the supervising physician when he/she is billing for services rendered by a Physician Assistant, (PA), Advanced Nurse Practitioner (APN) or Certified Registered Nurse First Assistant (CRNFA):

AS Modifier: A physician should use this modifier when billing on behalf of a PA, ANP or CRNFA for services provided when the aforementioned providers are acting as an assistant during surgery. (Modifier AS to be used ONLY if they assist at surgery)


Modifier AS Physician Assistant (PA), Nurse Practitioner (NP) or Clinical Nurse Specialist (CNS) assistant at surgery services.


Instructions

Append this modifier to appropriate procedure codes when Non-Physician Practitioners (NPPs) are assisting a principal surgeon as an assistant surgeon. The assistant at surgery provides more than ancillary services. NPPs include a CNS, NP and PA.


Correct Use

    The Medicare Physician Fee Schedule (MPFS) Indicator/Descriptor lists under column A will confirm if assistant at surgery is allowed.
        2 = payment restriction for assistants at surgery does not apply to this procedure. Assistant surgeon may be paid).
    NPP, mid-level practitioner or advance practice practitioner (APP)
        Append this modifier only
    NPP must accept assignment
    NPPs are allowed 85% of 16% physician fee allowable or 14% of surgery

Incorrect Use

    Inappropriate for NPPs to use modifiers 80, 81 or 82 (physician only modifiers)
    Modifier 80 (assistant surgeon), 81 (minimum assistant surgeon) or 82 (qualified resident surgeon not available) with physician (MD/DO) assisting at surgery

SA Modifier: A supervising physician should use this modifier when billing on behalf of a PA, ANP, of CRNFA for non-surgical services. (Modifier SA is used when the PA, ANP, or CRNFA is assisting with any other procedure that DOES NOT include surgery.)

Assistant Surgeon Modifiers


Modifier 80, 81, 82: Denote assistant surgeons. Should be submitted on those surgical procedures where an assistant surgeon is warranted. NOTE: Physicians acting as assistants cannot bill as co-surgeons. Benefits will be derived based on CMS designation for Assistant Surgeon.

-80 Modifier: PA’s, ANP’s, and CRNFA’s who are billing with their own provider number will not need to bill a modifier, unless they are billing as an Assistant Surgeon, then they must use the –80 modifier.

Billing and Coding Guidelines

A non-physician assistant-at-surgery is required to actively assist the surgeon and participate in the actual performance of the procedure. The operative report documents  the specific service(s) the non-physician assistant surgeon rendered.

Modifier AS should not be used if the Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist is acting as an “extra” pair of hands and not a surgical assistant in place of another surgeon.

Codes that are eligible for multiple surgical reductions will be adjusted when multiple surgical procedures are performed at the same surgical session.

Billing Reminder for Mid-level Practitioners

A nurse practitioner (NP), physician assistant (PA), and certified nurse midwife (CNM) must have his/her own provider identification number with BlueCross BlueShield of Western New York.

Direct services furnished by a NP, PA, or CNM are reimbursed at 80 percent of the physician fee schedule and must be billed by the mid-level practitioner using his/her own provider number. For a mid-level provider to receive reimbursement for services directly, the requirements are:

The services must be services that could be furnished by a doctor of medicine or osteopathy. The services must be within the New York state defined scope of practice for NP, PA, and CNM. NP services must be provided in collaboration with a physician. PA services must be supervised by a physician.

Examples to help determine who should bill for services rendered: Encounter Who Should Bill? Reimbursement Rate Physician performs service Physician 100 percent of fee schedule

NP/PA/CNM performs service NP/PA/CNM 80 percent of fee schedule NP sees patient but medical record clearly demonstrates significant physician input for patient encounter, including face-to-face contact Physician


100 percent of fee schedule NP/PA sees patient, physician co-signs note or states “concur with treatment plan” NP/PA/CNM

80 percent of fee schedule

Note: only one provider may bill for an individual patient encounter/service.

Coding Assistant at Surgery Services Rendered in a Method II CAH

An assistant at surgery is a physician or non-physician practitioner who actively assists the physician in charge of the case in performing a surgical procedure.
Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS).

Assistant at surgery services rendered by a physician or non-physician practitioner that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is billed on type of bill 85X with revenue code (RC) 96X, 97X or 98X and an appropriate assistant at surgery modifier.

Under authority of 42 CFR 414.40, CMS establishes uniform national definitions of services, codes to represent services, and payment modifiers to the codes. This includes the use of payment modifiers for assistant at surgery services.

Modifier 80 (assistant surgeon), 81 (minimum assistant surgeon), or 82 (when qualified resident surgeon not available) is used to bill for assistant at surgery services. When billed without modifier AS (PA, NP or CNS services for assistant at surgery) the use of these modifiers indicate that a physician served as an assistant at surgery.

Modifier AS is billed to indicate that a PA, NP or CNS served as the assistant at surgery.

Modifier 80, 81 or 82 must also be billed when modifier AS is billed. Claims submitted with modifier AS and without modifier 80, 81 or 82 are returned to the provider

Provider Types Eligible for Reimbursement for Assistant at Surgery Services

Moda Health considers the following provider types eligible for reimbursement for assistant at surgery services:

• MD (Medical Doctor)
• DO (Doctor of Osteopathic Medicine)
• PA (Physician’s Assistant)
• NP (Nurse Practitioner)
• RNFA (Registered Nurse First Assistant)

Provider Types Not Eligible for Reimbursement for Assistant at Surgery Services

The following provider types are not eligible for reimbursement of assistant at surgery service. Moda Health does not credential these provider types, and they are not eligible providers under our member plan language.

• Certified First Assistant (CFA)
• Certified Surgical First Assistant (CSFA)
• Certified Surgical Assistant (CSA)

These provider types are also not recognized by Medicare as eligible to bill or be reimbursed for assistant at surgery services.

Claims for services of CFAs, CSAs, or CSFAs, will be printed and returned to the billing office.

Contracted participating providers and groups are expected to not submit claims for assistant at surgery services performed by CFAs, CSAs, or CSFAs. Members may not be balance-billed for CFA services.

Assistant Surgeon Payment Adjustments

Procedure codes eligible for assistant at surgery reimbursement:

• Reported with modifier -80 or -82 appended will be reimbursed at 20% of the established fee.

• Reported by physician providers with modifier -81 appended will be reimbursed at 20% of the established fee.

• Reported by a non-physician provider with modifier -81 appended will be reimbursed at 10% of the established fee.

• Reported with modifier –AS appended, will be reimbursed at 10% of the established fee

PHYSICIAN ASSISTANTS

Louisiana Medicaid enrolls and issues individual Medicaid provider numbers to Physician Assistants (PA). Medicaid requires that all services provided by the PA be billed identifying the physician assistant as the attending provider.

Unless otherwise excluded by Louisiana Medicaid, the services covered are determined by individual licensure, scope of practice, and supervising physician delegation. The supervising physician must be a Medicaid enrolled physician. Clinical practice guidelines and protocols shall be available for review upon request by authorized representatives of Louisiana Medicaid.

Services  provided by a physician assistant shall not be billed when he/she is employed by or under contract with providers whose reimbursement is based on costs that include these salaries.

The reimbursement for services rendered by a physician assistant shall be 80% of the professional services fee schedule and 100% for KIDMED medical, vision, and hearing screens and immunizations.

Billing Information

Please note the following billing instructions and enrollment requirements regarding PA services

• PA services are billed on the CMS 1500/837P form.

• Services provided by the PA must be identified by entering the provider number of the PA in block 24J, and the group number must be entered in block 33B.

• Physicians who employ or contract with PAs must obtain a group provider number and link the PAs individual provider number to the group number. Physician groups must notify Provider Enrollment of such employment or contracts when PAs are added or
removed from the group.

• Qualified PAs who perform as first assistant in surgery should use the “-AS” modifier to identify these services.

Services rendered by the physician assistant that are billed and paid by Medicaid using a physician’s number as the attending provider are subject to post payment review and recovery.


First Assistant in Surgery

Louisiana Medicaid will reimburse for only one first assistant in surgery. Ideally, the first assistant to the surgeon should be a qualified physician. However, in those situations when a physician does not serve as the first assistant; qualified, enrolled, advanced practice registered nurses and physician assistants may function in the role of a surgical first assistant and submit claims for their services under their Medicaid provider number. The reimbursement of claims for more than one first assistant is subject to recoupment.

General reimbursement guide for NP and PA

A nurse practitioner (NP), physician assistant (PA), and certified nurse midwife (CNM) must have his/her own provider identification number with BlueCross BlueShield of Western New York. Direct services furnished by a NP, PA, or CNM are reimbursed at 80 percent of the physician fee schedule and must be billed by the mid-level practitioner using his/her own provider number. For a mid-level provider to receive reimbursement for services directly, the requirements are:

The services must be services that could be furnished by a doctor of medicine or osteopathy. The services must be within the New York state defined scope of practice for NP, PA, and CNM. NP services must be provided in collaboration with a physician. PA services must be supervised by a physician.

Encounter Who Should Bill? Reimbursement Rate

Physician performs service Physician 100 percent of fee schedule

NP/PA/CNM performs service NP/PA/CNM 80 percent of fee schedule

NP sees patient but medical record clearly demonstrates significant physician input for patient encounter, including face-to-face contact Physician 100 percent of fee schedule

NP/PA sees patient, physician co-signs note or states “concur with treatment plan” NP/PA/CNM 80 percent of fee schedule