Have you ever had a bill denied for services of your assistants and not known why? Have you received cryptic messages on an explanation of payments that indicates your assistant is not allowed to bill for services? As the use of professional extenders increase, this is becoming a more frequent issue.
Several surgeons have aired questions over the past year about denials on billing for their mid-level or advanced practice providers (APPs), physician assistants (PAs) or nurse practitioners (NPs).
Some of these denials are related to taxonomy code issues. Taxonomy is the classification of providers ticking away on computers in the background, about which many physicians know little. When a provider signs up to practice after getting the appropriate license, one gets an National Provider Identifier (NPI) number but also a taxonomy code number, which goes into the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and insurers’ computers. The taxonomy code tells the computer what type of provider you are. For physicians, this usually never changes, i.e., once a vascular surgeon, always a vascular surgeon. Many physicians never even know they have a taxonomy number as this is usually handled by credentialing employees when the physician first starts work. So, the problems are not with the vascular surgeon, but with the APPs.
For PAs, there are only three taxonomy codes, but issues occur when a PA starts work with a medical practice, changes jobs, and is hired by surgeons and does not change his or her taxonomy code. Then there can be conflicts with surgical groups being told that they cannot be with other groups in risk-sharing models (accountable care organizations) as the computer sees a primary care billing from the surgical group PA (the computer thinks this is still a medical PA), which cannot be allowed. When an APP changes jobs, it is important to review and update the taxonomy code.
For nurse practitioners, there are 18 taxonomy codes, and for certified clinical nurse specialists (CCNS) there are 34. None of those 52 codes specifies a surgical NP or CCNS. There can be problems with computers thinking that billings from these are medical providers rather than surgical providers.
To decrease problems, there are workarounds. None is perfect but they do allow some flexibility. First, one should be aware of these taxonomy codes and make sure that everyone is signed up with the correct code. The following section of the Centers for Medicare and Medicaid Services (CMS) website, vascular.org/TaxonomyDataset, is a good place to start to check the taxonomy codes. The PECOS (vascular. org/PECOS) can be checked to make sure the taxonomy code is correctly listed.
APPs traditionally are considered to be working in the same field/specialty as the physicians with whom they work. The supervising physician can be listed on a claim with the APP so the computer can recognize the specialty within which the APP is working, based on the physician’s taxonomy code. There must be a collaborative agreement between the APP and the physician to use the latter’s name/ code that pulls the service to a specialty. This is a separate issue from the desire of some APPs to have independent practices without a collaborative agreement with a physician.
For those in multispecialty groups with the same tax identification number, the taxonomy code for the physician can identify the separate specialty while the APP taxonomy code is not specific enough. Depending on the site of service, the physician can also edit/amend the note after seeing the patient and take over the billing under split/ shared service. Physicians then get the credit for the billing. This may play havoc with APPs’ pay if their remuneration is heavily based on work relative value unit (wRVU)/ billing production. But some electronic medical records have a way to track the APP productivity as well as the physician billing. These are some of the ways to avoid billing problems, but making sure the taxonomy codes are correct is the first step. If there are recurrent denials on APP billing, coordination between credentialing and billing staff can alleviate/resolve many of these problems.
Kevin Martin, MD, was writing on behalf of the SVS Coding Committee, of which he is a member.
