Physician Assistant Billing for New and Established Patients

Question:

Our Physician Assistant saw a new Medicare Patient in the office for evaluation of left knee pain. She evaluated the patient and developed the plan of care. The patient was scheduled for a return visit with the Physician Assistant. During the return visit, the Physician Assistant evaluated the patient and made no changes to the plan of care—she continued the NSAIDs as the patient responded well.

Can she bill this  “Incident to” the physician who was in the office, as there was no change in the plan of care?

Answer:

Thanks for your inquiry. Although the second visit involves an established patient with no changes to the plan of care or new orders, the Physician Assistant must  submit the claim as the service provider. The 'Incident to' requirements have not been met.

To move this to an “Incident to” encounter, there must be an independent encounter with the physician who either agrees with or changes the plan of care. After the physician independently evaluates the patient and either agrees with or modifies the plan of care, subsequent encounters with the Physician Assistant may be reported as 'Incident to' if the requirements are met (e.g., implementation of the plan of care without new orders or changes to the plan of care).

*This response is based on the best information available as of 3/13/25.

Bone Marrow Harvest for Ankle Arthrodesis

Question:

Our surgeon harvested bone from the calcaneus (same incision) and also harvested bone marrow from the iliac crest for an ankle arthrodesis. We know the bone graft from the calcaneus is not reportable. Is the bone marrow aspirate reportable? If yes, what CPT code do you recommend?

Answer:

You are correct that bone graft harvested via the same incision is not separately reportable. CPT instructs to report 20999 for the bone marrow harvest when performed for an arthrodesis in musculoskeletal system, excluding spine.

Based on your inquiry the correct code for the ankle arthrodesis is 27870 (Arthrodesis, ankle, open). Your reportable codes are 27870 and 20999.

Note, there are no NCCI edits between 27870 and 20999. Consider adding modifier 59 if necessary to indicate the bone marrow aspirate was from a different location, separate incision.

KZA recommends using 20939 as the comparison code for 20999.

*This response is based on the best information available as of 2/27/25.

7th Character for Cast Re-application

Question:

We are a bit confused about what 7th character code we should use when the patient is being seen in follow-up for a fracture. The initial encounter was reported with the “7th character” for the initial evaluation and application of cast or splint. When the patient returns and the surgeon re-applies a new cast, do we use the 7th character code for active treatment or the 7th character code for routine healing?

Answer:

Thank you for your inquiry. You are not alone in your confusion even 8 years after ICD 10 was implemented. You are correct to use the “initial treatment” (sometimes referred to as the active treatment) code for the initial evaluation of the patient. If the treatment plan is to apply a cast, and the patient returns, they are stable, healing has begun, the correct 7th character code for the fracture will be the “routine healing or follow-up care.”

Other examples of when you might use the 7th character for routine healing/subsequent encounter, in addition to the cast/splint re-application, are:

· Dressing change or removal

· Staple or suture removal

· Removal of external or internal fixation device

Some of the confusion stems from references to “initial” treatment and “active” treatment.

ICD identifies the 7th character, based on the location and type of fracture, to be:

• Initial

• Routine

• Delayed

• Nonunion

• Malunion

*This response is based on the best information available as of 2/13/25.

E&M and Injections: Is this billable?

Question:

We have a new patient presenting for evaluation of new elbow pain following a fall.  The provider documented a full history, exam, ordered and interpreted X-Rays.  Following this evaluation and discussion with the patient, they agreed the best option was to aspirate and inject the joint.  The procedure note documents the aspiration and injection of a corticosteroid. Does this meet the significant, separate service rules to report both the E&M and the aspiration/injection?  

Answer:

Based on the description of the encounter, KZA recommends reporting the E&M-25 and the injection code (20605) and the J code for the drug.  Remember, Medicare requires the JW or JZ modifiers effective July 1, 2023, if the medication was obtained from single-dose package.   Review with your private payors if they are following the same requirement.   

Rationale:  

New problem  

The intent of the visit was not the injection.  

Full E&M service performed.  

Joint decision making with patient on options and to proceed with minor procedure.  

*This response is based on the best information available as of 1/30/25.

Co-Planing of AC Joint

Question:

Our surgeon documented co-planing of the AC joint/distal clavicle. The diagnosis is bone spurs. Does this work support CPT code 29824, arthroscopic distal claviculectomy?  

Answer:

Thank you for your inquiry. Co-planing of the AC joint/distal clavicle does not support a distal clavicle resection. To report CPT code 29824, the documentation should include that the surgeon performed a “resection of the distal clavicle.” If the surgeon documents the amount, it should be based on the surgeon’s assessment of the amount of bone excised. 

In the early 2000’s the AAOS clarified the amount in the Global Service Data Guide that the amount of distal clavicle resection did have to be 1.0 cm. The AMA published a correction recently saying that the CPT code does not include the requirement of a specific bone-excision measurement of 1.0. This is consistent with the AAOS’s early position that the amount excised must be specific to the patient anatomy, physical size, and other factors. However, co-planing, removal of osteophytes, removal of bone spurs does not support a distal clavicle resection.  

*This response is based on the best information available as of 1/16/25.

Modifier 80 vs 82

Question:

What is the difference between modifier 80 and modifier 82 when a physician is acting as an assistant during surgery?

Answer:

While both modifier 80 and modifier 82 are used when a physician is actively participating as an assistant to a primary surgeon during a surgical procedure, modifier 82 is used in teaching or university hospitals that have approved Graduate Medical Education (GME) programs for Residents. In these teaching hospitals, there must be documentation indicating that no qualified resident was available to assist, to allow for another physician to act as the assistant surgeon, and then modifier 82 is appended to that assistant surgeon.

*This response is based on the best information available as of 1/2/25.