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Original Investigation |

Scope of Physician Procedures Independently Billed by Mid-Level Providers in the Office Setting

Brett Coldiron, MD1; Mondhipa Ratnarathorn, MD2
[+] Author Affiliations
1Department of Dermatology, University of Cincinnati, Cincinnati, Ohio
2Procedural Dermatology Fellow, TriHealth Good Samaritan Hospital, Cincinnati, Ohio
JAMA Dermatol. 2014;150(11):1153-1159. doi:10.1001/jamadermatol.2014.1773.
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Importance  Mid-level providers (nurse practitioners and physician assistants) were originally envisioned to provide primary care services in underserved areas. This study details the current scope of independent procedural billing to Medicare of difficult, invasive, and surgical procedures by medical mid-level providers.

Objective  To understand the scope of independent billing to Medicare for procedures performed by mid-level providers in an outpatient office setting for a calendar year.

Design  Analyses of the 2012 Medicare Physician/Supplier Procedure Summary Master File, which reflects fee-for-service claims that were paid by Medicare, for Current Procedural Terminology procedures independently billed by mid-level providers.

Setting and Participants  Outpatient office setting among health care providers.

Main Outcomes and Measures  The scope of independent billing to Medicare for procedures performed by mid-level providers.

Results  In 2012, nurse practitioners and physician assistants billed independently for more than 4 million procedures at our cutoff of 5000 paid claims per procedure. Most (54.8%) of these procedures were performed in the specialty area of dermatology.

Conclusions and Relevance  The findings of this study are relevant to safety and quality of care. Recently, the shortage of primary care clinicians has prompted discussion of widening the scope of practice for mid-level providers. It would be prudent to temper widening the scope of practice of mid-level providers by recognizing that mid-level providers are not solely limited to primary care, and may involve procedures for which they may not have formal training.

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Submit a Comment
Posted on August 15, 2014
Jennifer Winter PA-C
Society of Dermatology Physician Assistants
Conflict of Interest: None Declared
I am writing in response to an article published in JAMA Dermatology on August 11, 2014, titled "Scope of Physician Procedures Independently Billed by Mid-Level Providers in the Office Setting." My name is Jennifer Winter, and I am a Dermatology Physician Assistant. I feel qualified to respond to this article and its inaccuracies due to my experience. I have worked with the same dermatologist since 1989 and as a PA since 2000. I am also the Immediate Past President of the Society of Dermatology Physician Assistants (SDPA) and while the opinions in this article are my own, I have the support of my Society.
The article covers many issues, and I will try to cover each in turn. The first assertion is that PAs were originally envisioned to provide care in underserved areas. This is true, and I currently practice in an area that is underserved with respect to dermatology care despite a dermatology residency in my state. It is a 3-month wait for new patients in my practice for both physicians and PAs, though a newly hired physician will ease this somewhat. Many dermatologists are in a similar situation of needing to work with PAs and NPs in order to care for all the patients who need dermatologic care.
Medicare’s incident-to rules are somewhat complex and often misunderstood. The full text of the Medicare Benefit Policy Manual can be found here with incident-to rules in section 60.  http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf[cms.gov]
The AAD has a nice summary as well. http://www.aad.org/dw/monthly/2014/june/billing-medicare-for-incident-to-services#page1[aad.org]
The rules describe the situations which will permit billing a PA’s services as incident-to, however there is no discussion of what allows for independent billing as the article claims. Any clinic services that do not meet incident-to guidelines are billed independently by the PA and paid at 85% of the physician fee schedule. Only established problems that have had a care plan developed by the physician then managed by the PA can be billed as incident-to and billed under the physicians NPI at 100% of the physician fee schedule. So if I see a new patient and do the history and physical exam, even if the physician also examines the patient and contributes to developing a differential, the services cannot be billed as incident-to under Medicare rules. In order to qualify for incident-to rules, the physician would have to see all new patients and then transition them to a PA for ongoing management. This model disrupts continuity of care for patients and is not satisfying for patient, physician or PA. It also limits new patient access to what the physician can handle.
The 15% cut on Medicare billing that I take due to billing virtually all my services independently is offset by the continuity of care that I provide to my patients and the fact that I can see more patients if I do not have to wait for the physician to see any new problems that always seem to arise. I do not bill independently because I am not being supervised, I do it because the requirements for billing incident-to are not worth the extra 15%. I have at least one and generally 2-3 physicians on-site, and I have superb backup by my physicians. I have also had superb training, and, after all, this article appears to be primarily concerned with the possibility that inadequately trained providers are caring for dermatology patients. Unfortunately, the numbers don’t take into account the level of training of the performing provider, and the concern is based on a faulty understanding of the incident-to rules.
Now that we have clarified that independent billing of Medicare services does not require that the performing provider be unsupervised, the issue is who is using those codes referenced in the article. Dermatology is a procedure-based specialty, so it is not surprising that of the codes listed, over 50% are dermatological. That does not mean that dermatology providers are the only ones providing these services. We are all well aware that primary care providers of all types are making a determination of precancerous vs benign and performing cryotherapy. While the article focused on PA and NP billing of these codes, any dermatologist who has precepted for family practice residents is well aware that even those who are physicians, qualified, and board-certified to practice medicine without supervision are ill-prepared to perform many of these same procedures without additional training. Better to collaborate with the more available PAs, train them well so that they can make sound medical decisions, and then let them care for patients. This will reduce the backlog of patients who might otherwise turn to primary care to handle issues better cared for in a dermatology office.
I do not disagree with the authors that physicians have many more clinical hours upon completing residency than PAs do upon completion of PA training. I cannot speak to the 500-900 hours listed for NP training, but PA training includes 2000 hours of clinical experience. I am not suggesting that a new graduate or a PA new to derm should be let loose to make significant decisions without direct oversight. However, dermatologists were once non-dermatologists and had to learn all those skills. Just because a PA has not been through the same full medical school training does not mean they would not be capable of learning the same skills and applying them to benefit patients. It was Sir William Osler who said, “We miss more by not seeing than by not knowing”.
I agree that having more consistent and streamlined regulation of not only PAs and NPs but also physicians would help ensure a consistent standard of care and protect patients. I also agree that having mandatory reporting of complications could put patient safety concerns to rest, but only if all providers were subject to such reporting, including physicians. Having data on only PAs or NPs without comparing to physicians providing similar services will not allow a determination of increased complications, only that complications occur. A reference point is needed. Malpractice claims often serve as an indicator of unhappy patients and do not always point to poor medical care. Articles such as this one may serve to undermine the public trust in PAs. This may increase the risk of malpractice which is likely to impact the supervising physician as well as the PA.
Adequate training of PAs in dermatology is paramount to protect the patient. It is the duty of the supervising physician to allow increased autonomy only when appropriate to the level of experience and training of the PA. In all 50 states PA practice is allowed only in association with a supervising physician. Lack of formal training has been a criticism of derm PAs. The SDPA has worked with the AAD to increase educational opportunities for PAs and appreciate the ongoing and increasing support we are receiving from the AAD. Perhaps we can work together to develop a document that can track the training of derm PAs to alleviate that concern. Something like the Milestones Assessment for Dermatology Residents might be something dermatologists would be comfortable with.http://www.dermatologyprofessors.org/files/2013%20Annual%20Meeting/CCC%20-MILESTONES%20ASSESSMENT%20FOR%20DERMATOLOGY%20RESIDENTS%20Table%20Document%209-12%20v2ES2.pdf[dermatologyprofessors.org]
The AAD estimates that up to 50% of it’s members employ PAs and NPs. It is imperative that we work together to address concerns instead of undermining the confidence of the public and other health care providers in our care. The future of our specialty and the care of our patients depend on it.
I welcome the opportunity to discuss this article or any concerns you may have and thank you for the time and consideration you have given.
Jennifer Winter, MSPAS, PA-C
Immediate Past President
SDPA Diplomate
In reply
Posted on August 20, 2014
Brett Coldiron, M.D., F.A.C.P.
University of Cincinnati Hospital
Conflict of Interest: None Declared

Dear Ms. Winter,

As clearly stated in our article, mid-level providers were envisioned to be primary care physician extenders. State and national policy and payment decisions concerning mid-level providers have been based on the shortage of primary care physicians, not specialty physicians. 

 Medicare’s “incident to” rules are not onerous, and are most succinctly summarized in the Office of Inspector general’s report “PREVALENCE AND QUALIFICATIONS OF NONPHYSICIANS WHO PERFORMEDMEDICARE PHYSICIAN SERVICES, August 2009 OEI-09-06-00430.” 

The implementing regulations allow physicians’ reimbursement for services at the full physician fee schedule amount for services provided by their staff if the services are:

• furnished to beneficiaries who are not inpatients of a hospital or skilled nursing facility;

• commonly furnished in a physician’s office and are “an integral,although incidental, part of the service of a physician or other practitioner in the course of diagnosis or treatment of an injury or illness;”

• included in a treatment plan for an injury or illness, where the physician personally performs the initial service and is involved actively in the course of treatment;

• “commonly furnished without charge or included in the bill of a physician (or other practitioner);” and• furnished under the direct supervision (5) of a physician[42 CFR § 410.26(b)].”

Note that the footnote above (5) concerning direct supervision reads, “Direct supervision in the office setting means that the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed (42 CFR § 410.32(b)(3)(ii)).”

Thus, if a mid-level provider is billing independently and taking a 15% pay cut, it could be because the supervising physician has not seen the patient, is not actively involved in the care of the patient, or is not in the office. Ms. Winter claims to practice in an underserved area. Olympia, Washington, does not qualify as such, since has a population of 46,000, has twelve dermatologists, and is near Seattle. There are shortage areas of dermatology, but a reasonable solution might be to increase graduate medical education funding to train more dermatologists. 

Regardless, Ms. Winter, who also speaks for the Society of Dermatology Physician Assistants, clarifies that many of the dermatology physician assistant’s patients are not seen by the supervising dermatologist, either on the initial visit or subsequently. 

In addition, on January 10th, 2014, Ms. Winter, President of the American Academy of Physician Assistants (AAPA), reached out to the media in an effort to educate the public about the benefits of physician assistants (PA) in specialty medicine. She described what it is like to be a PA in her practice: “I have my own patient schedule, my own medical assistant, my own rooms, I see new patients, and I do my own surgeries, and see my own return patients.” She noted that her practice is supported by her team and by her supervising physician with whom she can request a consultation if needed at any point. “More patients can be seen this way,” she stated, “because we’re not overlapping with two different providers seeing the same patient in the same day.” This not only allows providers to become more familiar with their own patients, but it also benefits patients, who appreciate the continuity of care. She further explains that “we hope to increase the percentage in the future to allow more opportunities for PAs to work in dermatology, because the specialty provides a high quality of life.”

The independent practice of mid-level providers needs closer scrutiny to ensure public safety when considering the complexity of any medical care, in particular when the decision is made by a mid-level provider to perform an invasive surgical procedure. Thus, a patient may schedule an appointment to see a specialist physician, never see a physician, and not know the provider is not a physician. In fact, the person they see, and who decides to perform invasive procedures on them, has no formal training in dermatology. If this is not outright consumer fraud, then it is at a minimum deceptive. Ms. Winter claims this enhances the continuity of care. I would maintain it enhances her and her employers’ income. I also think that the “awkward introduction” of a supervising physician to the patient, will make it clear to the patient that the person treating them is not a physician and makes the deception more difficult. 

I was not aware that physician assistant school provided 2000 hours of clinical training, three times as much as nurse practitioners. This training is not focused in dermatology, and does not compare to the over 14,000 hours (minimum four years) of formal clinical training a dermatology resident must complete after medical school, before he or she is deemed ready to diagnose and treat patients in an unsupervised fashion. It must also be pointed out that the current ACGME supervisory requirements of a resident physician are much more extensive than that of a mid-level provider, and the resident physician must have successfully completed medical school. 

If I were a patient, I would happily pay 15% more to see someone with 7-20 times the clinical training. I think patients are unaware physician assistants are not doctors. An AMA survey showed that 84% of respondents said they prefer a physician to have primary responsibility of their health care (1). This is why policymakers and consumer advocates should support medical transparency laws, where the individual who treats a patient must wear a prominent badge explaining what their formal training is. Ms. Winter also states that she has had superb training, but she does not detail that training. There are no ACGME residencies for physician assistants. Physician assistant programs generally are 27 months in length and focus on primary care, not dermatology or other specialty medicine. Ms. Winter may be unaware that physicians’ are already subject to publicly reporting and/or recording in their medical records, office surgical complications in 12 states, including Florida, Alabama, Georgia, Kentucky, Louisiana, New York, North Carolina, Oregon, South Carolina, Tennessee, Virginia, and Washington. There are no such clear reporting requirements for mid-level providers, who may or may not be practicing under physician supervision, and may report to a nursing board and not a medical board. 

In addition, a mid-level practitioner trained in primary care, without specialty training in surgery, or interpretation of complex diagnostic tests, should be held to a higher reporting standard than a physician. The bar is set high to receive an unrestricted license to practice medicine in the United States. Typically, the physician needs to graduate from an accredited medical school, pass parts I – III of the USMLE, and complete at least two years of ACGME accredited post–graduate training. To achieve board certification by ABMS or AOA requires several more years. Ms. Winter correctly points out there are huge malpractice risks for mid-level providers who provide unsupervised care. If there are bad outcomes, the absence of physician supervision, and lack of formal training in dermatology will become devastatingly obvious in court. A surge in large malpractice settlements for mid-level providers using lasers has been noted, and more should be expected. Malpractice claims usually involve a serious injury, but torts are a poor method of insuring quality. Only a fraction of injured patients sue, and of those, only fractions receive compensation. It would be far better to prevent such injuries or misdiagnoses, hence our call for enhanced reporting of office complications, by mid-level providers. The August 2009 OIG report concludes, in part, “Services performed by unqualified non-physicians represent a risk to Medicare beneficiaries.” The extent of this risk is still not known, hence our call for data collection, transparency to patients, and a call for Congress to realign payment of mid-level providers back to primary care, which they are trained to help provide. 

Sincerely,Brett Coldiron, M.D., F.A.C.P.

Cincinnati, Ohio

1) Global Strategy Group conducted a telephone survey on behalf of the AMA Scope of Practice Partnership between August 13–18, 2008. Global Strategy Group surveyed 850 adults nation- wide. The overall margin of error is +/- 3.4 percent at the 95 percent confidence level.

PAs Can and Do Earn Specialty Credentials
Posted on August 25, 2014
James D. Cannon, DHA, MBA, PA-C
Chair, NCCPA
Conflict of Interest: None Declared
Dr. Robinson:This letter is in response to the article “Scope of Physician Procedures Independently Billed by Mid-Level Providers in the Office Setting,” published Aug. 11.As Board Chair of the National Commission on Certification of Physician Assistants (NCCPA), I want to clarify what is required by physician assistants (PAs) to become certified and inform your readers about additional specialty credentials that PAs can and do earn.We understand the concern of dermatologists. However, now is the time for all healthcare professionals – physicians, PAs, NPs and others – to look at the reality of our healthcare system – and what is best for patients. In the midst of a shortage of physicians in many areas PAs can help support and enhance access to care. Patients want and need committed, educated and skilled healthcare providers with not only the training, but also the time and experience to ensure they get the best care possible. That is what certified PAs are doing and will continue to do.The demand for PAs is growing because we provide high quality and cost effective care. Today, there are approximately 100,000 certified PAs that work in every specialty and clinical setting. Trained in the medical model, certified PAs are highly educated, and must pass a rigorous national certification exam for initial licensure by all 50 state medical boards. Over 96% maintain certification through a process similar to physicians. PA certification is comprehensive. It requires:•Graduation from an accredited program (most of which now award master’s degrees)•Passing a rigorous, generalist initial certification exam that covers the wide range of human disease and medical conditions•100 CME credits every two years, including – 20 credits in self-assessment and/or performance improvement CME. •Passing a comprehensive recertification exam every 10 years.In addition, PAs in seven specialties can earn additional specialty credentials, the Certificate of Added Qualifications (CAQ) in the following: cardiovascular and thoracic surgery, emergency medicine, hospital medicine, nephrology, orthopaedic surgery, pediatrics and psychiatry. The CAQ program requires PAs to earn additional specialty-focused experience and CME, a physician attestation of the PAs skills in that specialty and also successfully pass a national specialty exam. Surgical procedures are an area where PAs have solidly demonstrated a special skill and ability. Over 19% of PAs work in surgical specialties successfully delivering care as proof of this fact.Please contact us directly if you would like to schedule time to discuss this in more depth.James D. Cannon, DHA, MBA, PA-C Board Chair, NCCPA
Corrections to Unfounded Assumptions and Inaccuracies in \"Physician Procedures Independently Billed by Mid-Level Providers in the Office Setting\"
Posted on September 12, 2014
John McGinnity, MPS, PA-C, DFAAPA
AAPA President
Conflict of Interest: None Declared
It is both surprising and unsettling that an article (Scope of Physician Procedures Independently Billed by Mid-Level Providers in the Office Setting, Aug. 11, 2014) with a number of unfounded assumptions and inaccuracies would be printed in a publication with the reputation of JAMA.“Midlevel provider” is a demeaning and antiquated term to use in reference to PAs, who should be referred to by their professional title. The authors further demean PAs by alleging that PAs earn up to 900 clinical hours during their pursuit of a master’s degree in “physician assistance.” There are 187 accredited PA programs in the US that rigorously prepare PAs to practice medicine and require over 2,000 hours of supervised clinical practice, along with a year of didactic education, to confer master’s degrees in science and medicine. The article is based on two incorrect assumptions. The authors allege that if PAs bill using their own NPI numbers that they are engaging in independent practice. “Independent billing” does not equal “independent practice.” The authors assert independent billing is only allowed when the physician is “not on the premises.”A claim billed using a PA’s NPI number provides no information about whether or not a physician was onsite. Many PAs bill using their own NPI number even when a physician is onsite as it allows the PA to see a new patient or a patient with a new problem. This is in compliance with Medicare requirements. The second incorrect assumption is that the most common procedures billed indicate PA practice in the specialty area of dermatology. The most common code billed was “destruction of pre-malignant lesion, 2-15.” This code is also widely used in primary care and is not exclusive to dermatology. About 4.3 percent of over 100,000 certified PAs in the country practice in dermatology compared to 20 percent who practice specifically in family medicine. The authors employ their incorrect assumptions to support changes in medical regulation and payment which is extremely detrimental to the PA profession.The PA profession is committed to providing evidence-based and high-quality medical care. In the future, we ask the editors to more closely check facts in articles regarding PA practice. More than 6,000 PAs enter the workforce each year, and it would be prudent for JAMA to ensure that articles focused on PAs are accurate.
In Reply:
Posted on October 23, 2014
Binh Ngo
Assistant Professor of Dermatology, Keck School of Medicine, USC
Conflict of Interest: None Declared

The article: Scope of Physician Procedures Independently Billed by Mid-Level Providers in the Office Setting by Coldiron and Ratnarathorn in the August edition of JAMA Dermatology (1) and the letter Expanding Scope of Dermatologic Mid-Level Practitioners Includes Prescription of Complex Medication by Pascoe and Kimball (2) raise awareness of an alarming trend to substitute physician extenders for trained and qualified physicians in the diagnosis and treatment of complex conditions. Dermatology is a specialty requiring four years of training. Board certification requires documentation of adequate performance on a large number of procedures and success on a difficult examination and subsequent recertification at ten year intervals. Physician assistants and nurse practitioners do not have this training, nor proof of adequate performance. The original intent to expand primary care was to allow physician extenders to deal with common conditions with simple treatments. That intent has been grossly perverted. The Medicare payment data cited by the authors confirms the reality that physician extenders are now independently evaluating complex conditions and performing surgical procedures without physician overview. I have seen many cases where improper care was delivered by such unsupervised staff. For example, an electrodesiccation and curettage was performed on an invasive squamous cell carcinoma on the scalp, a lupus rash misdiagnosed as contact dermatitis, and mastitis misdiagnosed as contact dermatitis and improperly treated with prednisone. In some practices, these staff members perform Mohs surgery on difficult to eradicate skin cancers, procedures wherein dermatologists typically receive an additional year of Fellowship training. The role of a physician extender should be to supplement the work of a physician, not to practice medicine autonomously. Patients are often shunted to physician extenders when they arrive for appointments with the physician. They should be informed beforehand whether the doctor or physician extenders will be seeing them in the office and who will be doing a procedure on them. If given the choice, patients overwhelmingly want their care to be provided by qualified professionals (3). The current trend to degrade qualifications of those providing needed care is fueled by the desire of government and insurers to lower the cost of health care, abetted by the greed of physicians who want to bill for care they do not perform. Foreign medical graduates who have been trained in their country of origin are obligated to pursue a full course of post graduate residency in the United States before they can carry out a specialty. Physician extenders should likewise have a full course of specialty training prior to being allowed to function in complex activities.

REFERENCES:1) Coldiron B, Ratnarathorn M. Scope of Physician Procedures Independently Billed by Mid-Level Providers in the Office Setting. JAMA Dermatol. 2014 Aug 11. doi: 10.1001/jamadermatol.2014.1773. [Epub ahead of print]2) Pascoe VL, Kimball AB. Expanding scope of dermatologic mid-level practitioners includes prescription of complex medication JAMA Dermatol. Published online October 15, 2014. doi:10.1001/jamadermatol.2014.32953) Bangash HK, Ibrahimi OA, Green LJ, Alam M, Eisen DB, Armstrong AW.Who do you prefer? A study of public preferences for health care provider type in performing cutaneous surgery and cosmetic procedures in the United States. Dermatol Surg. 2014 Jun;40(6):671-8. doi: 10.1111/dsu.0000000000000016.

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