OIG Focus: Know the Ins and Outs of Incident To

Late last year, the Office of Inspector General (OIG) released its work plan for fiscal year 2002, outlining areas of federal healthcare spending (i.e., Medicare and Medicaid expenditures) to receive special oversight for the next year. Among the goals of the program are isolating instances of fraud and misconduct, "reducing hospital payment errors" and "evaluating the efficiency of controls over Medicare payments for medical education."

Areas targeted for special scrutiny include E/M coding, procedure coding of outpatient and physician services (outpatient services billed by a hospital and a physician for the same service), consults and the use of advance beneficiary notices (ABNs). And, for the second year in a row, "incident to" billing (services/supplies billed by the physician but provided by allied health professionals such as nurses, technicians and therapists) will be the focus of increased OIG attention. The continued investigation of incident-to billing serves as notice that physicians consistently have difficulty in this area. But by understanding a few basic requirements, allergists can avoid common billing mistakes.
Play by the Rules to Get Paid by the Rules
Medicare defines "incident to" services as services provided by a nonphysician practitioner (NPP) such as a nurse practitioner, physician assistant or clinical nurse specialist and which are an integral part of the physician's personal professional services in the course of a diagnosis or treatment of an injury or illness, says Ron Nelson, PA-C, reimbursement policy analyst, president of Health Services Associates Inc., a family practice in Fremont, Mich., and past president of the American Academy of Physician Assistants. For example, allergists may employ an NPP to perform diagnostic tests or injection services. Services provided incident to are reported using the appropriate CPT codes under the supervising physician's personal identification number (PIN) and are reimbursed at 100 percent of the Physician Fee Schedule. Services provided by medical assistants or nurses are also subject to incident to guidelines.
Note: In many allergy offices, an NPP, such as a nurse practitioner or physician assistant, will see patients in much the same way as a physician, and will bill using his or her own PIN. Incident to services are distinct from such services provided by an NPP using his or her own PIN, which follow different guidelines and are generally reimbursed at 85 percent of the Physician Fee Schedule rate.
There are four main guidelines for billing incident to, as outlined in section 2050 of the Medicare Carriers Manual (MCM). The NPP providing incident to services does not need to be licensed under state law as long as four requirements are met:
The physician must be involved: The allergist must see all patients to establish diagnoses [...]

- Published on 2002-06-01