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.

Layered Closure with Lesion Excision

Question:

Our practice performs many excisions of lesions with closures. My question is related to the closures. Is the provider documenting the closure in layers enough to report an intermediate repair if the tissue level is not?

Answer:

Great question!

We know that lesion excisions and closure with either intermediate and/or complex closure are appropriate to report together if the documentation supports it. In contrast, closure with simple repair is an included lesion excision and is not separately reportable.

The CPT guidelines are essential and should be reviewed carefully, as the definitions of each closure type can be found here. To report a closure accurately, it is best practice to include the type or level of tissue being repaired. KZA would encourage you to review the CPT guidelines for closures with your practice for documentation purposes. As you can see from the guidelines within CPT, the type and tissue level are factored into the definitions.

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

Craniectomy for Tumor Resection

Question:

Patient had a posterior fossa craniectomy for excision of a mass which was consistent with metastatic tumor. Pathology results report the mass as a partially cystic metastatic tumor.  What is the correct code 61518 or 61524?

Answer:

The correct CPT code is 61518; a metastatic tumor is still a tumor even if it is partially cystic.

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

Billing Stages for Mohs

Question:

I am very confused. I am new to coding for Mohs procedures. The Mohs surgeon performed a procedure on the patient’s scalp in 5 stages. I spoke with the Mohs surgeon about billing over 4 stages in one area using CPT code 17312. He billed 17311 for the first stage and 17312 with 4 units for a total of 5 stages. In each stage, the documentation states that 1 tissue block was mapped. I think we should bill CPT 17315 for the last stage instead of 17312 since it is the 5th stage. Can you clarify if this is the case or if 17312 with 4 units is correct.

Answer:

I agree with your Mohs surgeon. The only time you use 17315 is when there are more than 5 tissue blocks per stage. Based on the information you have provided each stage indicates 1 block. CPT code 17311 should be reported for stage 1 and 17312 is reported for each additional stage (4).

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

Abdominal Hernia Defect Size

Question:

Our general surgeon often does not include the size of the abdominal repair in his documentation; can we use the pathology report to determine the correct size for CPT selection?

Answer:

No; the provider must document the hernia defect size within his/her operative report details to accurately select the correct CPT code. The pathology report would likely represent the tissue size, which would not necessarily correlate to the defect size. Best practice is to send a query to the provider asking him/her to add an addendum to the operative report, adding the defect size and advise that this information is required in the documentation.

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

Use of Robotic Systems During Surgical Procedures

Question:

What is the code for a robotic procedure?

Answer:

When surgical procedures involve the use of robotic surgical systems, the robotic component can be represented by HCPCS code S2900. However, there is no RVU associated with this code, and it is not reimbursed under the Medicare payment system. Best practice is to set a fee for the extra physician work involved with robotic assistance, document medical necessity for use of the robot and incorporate this code into billing for tracking purposes, when used.

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