nurse practitioner seeing a patient in clinic and and a doctor in the ASC which is just across the hall 10 feet away. Can you bill for the physician? Nope. The place of service has got to be office. The place of service for the ASC is 24. Place of service for office is 11. So they have to be in the office suite and readily available. All right well and Kristen signed up for this one. Infusion administration requires direct supervision 96413. Can a physician's assistant be in the office as the supervising provider and the claim get billed under the physician's assistance NPI? Does an attending provider have to be in the office suite? Can a PA initiate biologic treatment and be the supervising provider throughout the care of the patient? All right so for billing purposes they can. They can initiate the treatment and they can be if they're in clinic while that service is rendered that you can bill under their number. Just keep in mind it's going to be the 85 percent fee reimbursement for fee schedule versus 100 percent if you would bill under the physician. But sometimes our physicians are not there. They are across in the ASC doing a procedure so you can bill that infusion services under that PA. Anybody any you two want to comment on that? I'd probably make one comment because I'm working with the with a practice right now that was having an issue with a couple payers Medicaid being one of them that also was discounting the medication by 15 percent as well which they really shouldn't. They should not be discounting supplies at all. So I think if you're going to have to see realistically in that situation then you're discounting not just a little bit of nothing but you're discounting hundreds potentially to thousands of dollars with it 15 percent then you make sure that those patients are scheduled when there is a physician on site in the office that day. I mean that's just something that you're going to have to do a workaround on. Okay and Kristen what are the advantages and disadvantages of hiring a nurse practitioner versus a physician's assistant? Well that's a good question. They're both I mean they're both billing providers. There are some and maybe Dr. Littenberg you could comment on this one or Kathy chime in that there might be a little bit more restriction on a PA and their scope of practice versus what a nurse practitioner can do. But as far as in the billing world most payers that accept claims under an advanced practitioner do accept a claim under the PA as well. You know they're they're meant to extend I guess that's that's one thing is they're they're meant to extend the services out. So while you know your PA's or your NP's are seeing patients in clinic you might be able to add on two more scopes for the day or you can see initial consults etc. But as far as the differences between the two I think I'll Dr. Littenberg you can comment on if you've had experience between the two. Yeah I think one reason maybe to look at a nurse practitioner is if you're going to utilize them in the hospital because they generally have a lot more clinical background and have that inpatient background as they've gone through their nursing and they've gone through their advanced degree. And even if they don't come out of the program with GI specific experience they can fairly easily acquire it and get good judgment. So if you have a busy hospitalist practice again you as a physician are spending a lot of time in the endoscopy lab doing procedures and the nurse practitioner can make you very efficient at getting the consults done getting your follow-up rounds done which which then you know you spend most of your day doing endoscopy that can be an extremely beneficial working relationship. In the office I don't know that necessarily makes a lot of difference which type of practitioner you get it's really more dependent on the individuals and and their background and their knowledge in GI or how quickly they get acclimated to GI cases. Some practices utilize the APPs more for certain kinds of patients when we were doing a lot of hepatitis C treatment for instance you know that that would be kind of a rote way of an evaluation which didn't involve a lot of variables from patient to patient you do the same things with with the same patients. So some practices are organized that way some use them primarily for follow-up visits because of the incident two rules and the physician sees the new patients but again if your access is a problem and you're backed up you know weeks months for new visits being able to add an APP usually much more easily than a physician usually always that can be very beneficial and and generally the way they their work is organized their work pays for itself doesn't necessarily make a large margin for the practice and many of them will work at a slower pace than an experienced physician will but they generally do very good documentation and they're very hands-on with the patients and do very good care. So majority of GI practices are probably using one or more APPs some even one-to-one or more than one-to-one with numbers of physicians in the in the practice. My own group we have one PA now we had two before the pandemic but it makes a big difference in availability and they they you know she pretty much works independently in other words seeing any patient who comes in the door I'd rather take the 15% cut and keep the access better rather than have to be fussing about how much hands-on I have during the visit when the patient's in the office. I supervise everything she does discusses everything with me. I write some you know additional notes but they'll mostly get billed under her number as a PA. So they were very beneficial but there are some differences and you just have to look at your own circumstances what what kind of person is better suited to you. Nurse practitioners will generally have a higher salary than PAs but you know worth it in many respects. Okay we've got two more questions and then we're going to do a five-minute break just in case we always like to give people a bio break in the afternoon so we'll push through these two questions and then we will break for five minutes to keep us relatively on track today. The next question is I'm not sure if I just missed this but if you would like let's see if you would like the patient to check in after treatment via portal to determine if a subsequent procedure is necessary that is check in via portal after PPI trial to see if EGD is needed would this count as patient initiated? That makes sense. I'd view as long as you're not sending them an email I need to know how you're doing you know if they're really following up on your recommendation that they contact you then yes it would but whether you wind up spending you know more than five minutes and can bill something based on that encounter just depends on the complexity of what's what's done. So it can be by portal it can be by phone their methods of billing for either one of the exchange or the in episode of care is what I call it an episode of care exceeds the threshold for that. And then our final question is can of this segment is can an MA bill for phone calls can an MA bill for phone calls? Unfortunately no. Usually an MA is following through on something related to a immediately preceding visit or upcoming visit whether reminding the patient go get your lab before you come in or we need to you know get some records from you who did you see where did you go for that x-ray whatever things like that sort. It's really incidental to a visit either pre-work or post-work and the physician is getting paid for that. So in effect they're getting paid but not directly they can't directly bill. It's a little different if it's an office service then we're talking about 99211 which we'll have more discussion that's certainly apropos.

billing

nurse practitioners

physician assistants

reimbursement

documentation