Editor’s Note: Cutting through the red tape to make certain that you get paid for every dollar you earn has become more difficult than ever, particularly in our current climate of health care reform and ICD-10 transition. The ACEP Coding and Nomenclature Committee has partnered with ACEP Now to provide you with practical, impactful tips to help you navigate through this coding and reimbursement maze.

Question: How should examinations performed by advanced practice providers (APPs) be documented?

Answer: Physician assistants (PAs) and advanced practice registered nurses (APRNs) are commonly referred to as APPs. PAs must always work in collaboration with a supervising/participating physician. In contrast, many states allow APRNs to practice independently, while others impose limited restrictions. That being said, when working in an emergency department, they are generally incorporated into the workforce in the same way. Three levels of oversight can occur. First, depending on state licensing, patients may be seen by an APP, and this may or may not require review or co-signature by the physician. Second, patient care or tests results may be reviewed and discussed with the physician. In both of these cases, the visit would generally be billed under the APP’s provider number and paid at varying percentages of the physician fee schedule based on the payer. If the physician documents they personally participated in the evaluation of the patient (face-to-face time required), then the visit may be attributed to the physician by some payers using the Centers for Medicare and Medicaid Services shared services rule. It is important to note that payer approaches to reimbursement of claims submitted for services rendered by APPs are variable.

See the ACEP FAQ on mid-level providers at for further details and suggested wording of attestation statements.

Brought to you by the ACEP Coding and Nomenclature Committee.

Dr. Lemanski is associate professor of emergency medicine at the University of Massachusetts School of Medicine–Baystate in Springfield.