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Tamper-resistant Medicaid prescriptions, billing for PAs

From the November/December ACP Observer, copyright 2007 by the American College of Physicians.

By Brian Whitman

Practice RxQ: I heard that all Medicaid prescriptions now have to be written on tamper-resistant prescription pads. What do I have to do?

A: According to a law passed by Congress in May 2007, physicians writing prescriptions for patients covered by Medicaid would have been required to issue tamper-resistant prescriptions as of Oct. 1. However, in September an extension granted a six-month delay in this implementation deadline, moving the start date to April 1, 2008. Physicians should use this additional six months to prepare for the requirement.

Since Medicaid is administered by individual states, there is wide latitude in how states may interpret the guidelines. However, Medicare has detailed that a tamper-resistant prescription:

  • prevents unauthorized copying of prescriptions,
  • prevents the erasure or modification of information written on a prescription, and
  • makes it difficult for counterfeit forms to be created.

CMS required states to meet at least one of the elements above by April 1. By Oct. 1, 2008, all Medicaid prescriptions must meet all three requirements.

It is important to note that this requirement applies to all prescriptions for Medicaid patients and not just to controlled substances that are often restricted under state laws and Drug Enforcement Administration regulations. Patients that are seen through managed care organizations that are contracted by state Medicaid agencies are not subject to the tamper-resistant prescription requirements. In addition, patients covered by both Medicare and Medicaid (dual eligibles) are not required to receive tamper-resistant prescriptions. Physicians should look for further guidance from their state agencies that handle Medicaid.

Q: I recently hired a physician assistant and am not sure how to bill Medicare for his services. How do I do so?

A: A physician assistant (PA) may bill Medicare for services under his or her own provider number or under the supervising physician’s Medicare provider number. Any time the PA bills Medicare under his own provider number, he will be paid 85% of what a physician would be paid under the physician fee schedule. If a PA provides evaluation and management (E/M) services to new patients in the office setting, then the PA should bill Medicare under his own provider number.

In many cases, subsequent office visits for patients seen by PAs should be billed under the PA’s provider number as well, particularly when the PA performed the initial visit at which the treatment plan for a particular ailment was designed. There are situations in which a PA can bill under the physician’s Medicare number, but a number of important requirements must be met. First, the service must be considered “incident-to” a physician service, meaning it’s part of a normal course of treatment for an established problem and that the physician remains actively involved in some way in the treatment. This does not require that the physician see the patient on the day that the PA does, but the physician must be guiding the treatment.

In addition, the physician under whom the service will be billed or a member of the group must be in the office for a service to be billed “incident-to.” The physician is not required to be in the room when the service is provided, only in the office suite. “Incident-to” billing is not allowed if a PA provides services in a facility setting, such as a hospital.

Any services provided by a PA in a hospital or a nursing facility must be reported using the PA’s provider number, and will be paid at 85% of the physician fee schedule.

Q: Is there a code that I can use for ambulatory blood pressure monitoring? Does Medicare pay for this service?

A: Yes. Four codes require a system that records blood pressure over a 24-hour period. One describes the entire service and the other three codes describe discrete elements of the service which, when combined, would constitute the entire service. Use these CPT codes for various combinations of these services:

  • Use 93784 if you provide data recording, scanning analysis, interpretation and report of ambulatory blood pressure. National average Medicare payment: $72.38.
  • Use 93786 if only the recording is performed, which does not involve any physician work. National average Medicare payment: $34.49.
  • Use 93788 if only scanning analysis and report is provided, which also does not involve any physician work. National average Medicare payment: $19.71.
  • Use 93790 if you only review and interpret the data and provide a report. In this case, the professional work of the physician is all that is reimbursed. National average Medicare payment: $18.19.

Q: Does Medicare limit to whom I can provide this service?

A: Medicare indicated that it will be a covered service only in the event of suspected “white coat” hypertension. Medicare defines those with suspected white coat hypertension as:

  • office blood pressure >140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit,
  • at least two documented blood pressure measurements taken outside the office which are <140/90 mm Hg, and
  • no evidence of end-organ damage.

It would be very rare for a patient to receive ambulatory blood pressure monitoring on more than one occasion, Medicare indicates in the NCD.

Brian Whitman is Senior Analyst for Regulatory and Insurer Affairs in ACP’s Washington, D.C. office.

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