Medi-Cal

MEDI-CAL is California’s version of Medicaid. Both Medicaid and Medicare are administered under the federal Centers for Medicare and Medicaid Services (CMS). Be aware that although Medicare and Medi-Cal fall under the administration of CMS, the rules and regulations for billing under these two payers are very different.

The Medi-Cal billing manual, under a section titled Non-physician Medical Providers (NMP), clearly recognizes the services of PAs and will reimburse for physician services provided by PAs at 100% of what a physician would receive for those covered services. The NMP section of the Medi-Cal Provider Manual under General Medicine describes the required enrollment process with the current forms to be used along with other criteria for allowable reimbursement for PAs. Enrolled PAs must work with a physician who is an enrolled Medi-Cal provider. The PA is not considered an independent Medi-Cal provider.

The billing for covered medical services provided by a PA is submitted under the (Medi-Cal enrolled) physician’s name and identifier with a modifier “U7” which is used to indicate the service was provided by a PA. Other modifiers may additionally be required for a particular service. Before 2009, PA billing was severely limited to a short list of CPT codes thereby restricting what services could be reimbursed. CAPA’s legislative efforts resulted in the elimination of that restrictive list and the manual now states that:

Covered services for PAs include services performed by a PA within the scope of practice when the services would be a covered benefit if performed by a physician and surgeon.

For PAs who provide first-assistant at surgery services, the Manual, under the section Surgery: Billing With Modifiers, explains how to use modifiers “99 = U7 + 80” along with the appropriate surgical procedure code billing under the physician.

Note: When reading this Manual, pay attention to the date in the right lower corner of the page which indicates the last date when any changes were made to the page.