Guard against Post-Payment Audits for Services by Non-Physician Practitioners
Published on Tue Dec 01, 1998
More and more cardiology practices are hiring non-physician practitioners (NPPs) such as physician assistants (PAs), nurse practitioners (NPs), and clinical nurse specialists (CNS), to provide services that traditionally have been performed by physicians. For example, depending on a states scope of practice law, a physician assistant could take history and physicals, render an independent evaluation or treatment of the patients condition, perform consultations, and assist in cardiac catheterizations, explains Ron Nelson, PA-C, president, HSA Consulting Group in Fremont, MI and president of the "American Academy of Physician Assistants".
However, unless you learn the intricacies of correct billing for these services provided by NPPs, your cardiology practice could be subject to a post-payment review and reduced reimbursement, experts warn.
Here are the five most common misconceptions cardiologists and their coders have about billing the use of NPPs, and how to correctly code them:
1. Bill incident to without non-physician provider ID number. Many practices believe that they dont need a billing number for their PAs, Nelson says. Because theyre getting paid, they assume their continued use of incident to is okay. However, using this option in every circumstance without meeting all the requirements can open your practice up to fraud and abuse accusations, Nelson warns.
Alice Gosfield, attorney with Alice G. Gosfield and Associates in Philadelphia, PA, agrees. Gosfield goes on to say that while Medicare carriers wont evaluate incident to on the basis of a claims submission, they may indeed ask you to prove it in a post payment audit, she explains.
Tip: Medicares incident to rule is defined as - services or supplies that are furnished as an integral, although incidental part of the physicians personal, professional services in the course of diagnosis or treatment of an injury or illness.
To be covered as incident to the services must be:
a. an integral, although incidental, part of the physicians professional service;
b. commonly rendered without charge or included in the physicians bill;
c. of a type that are commonly furnished in physicians offices or clinics;
d. furnished under the physicians direct personal supervision; and
e. furnished by the physician or by an individual who qualifies as an employee of the physician.
2. Bill incident to for NPPs who make hospital rounds. The incident to provision can only be used for services and procedures done by the NPP in the physicians office, not in a hospital or nursing facility, the experts stress.
If you use NPPs to make rounds in the hospital, fine, explains Gosfield. But this can only be reimbursed at 85% of the fee schedule using the NPPs number.
Your practice should not bill incident to and expect to receive 100% of the physician fee schedule. Otherwise, you will open your practice up to a post-payment review [...]
