Gastroenterology Coding Alert

Recover an Additional 15 Percent

Incident-to is defined by Medicare as services or supplies furnished as an integral, although incidental, part of the physician's personal professional services in the course of a diagnosis or treatment of an injury or illness. Medicare reimbursement policy for incident-to services allows you to report certain services rendered by NPPs under the supervising physician's number.
 
The result: You receive reimbursement for those services at 100 percent of Medicare's allowable Physician Fee Schedule instead of 85 percent of the fee schedule allowed under the NPP's number, says Judith Richardson, RN, MSA, CCS-P, a senior consultant with Hill & Associates in Wilmington, N.C.
 
Keep in mind that while NPPs can handle more in-depth services and bill incident-to, state regulations determine the allowed services they may perform. You should make sure your licensed NPPs follow the local regulations for prescribing, ordering tests, and performing other services.

Play by the Rules - Win the Game

 Medicare has four incident-to guidelines:

 1. Incident-to services must be integral, although incidental, parts of the physician's professional services. "This makes it clear that the doctor must be involved in the patient's care," says Michael Powe, director of health systems and reimbursement policy for the American Academy of Physician Assistants (AAPA). "The physician must personally treat, diagnose and develop a treatment plan on the patient's first visit to the practice for a particular medical problem. Subsequent care and services can then be delegated, and billed incident-to."
 
The supervising physician must also personally treat and diagnose established patients who are being seen for a new problem or condition. Be aware that services by a NPP may be billed under his name and Medicare number if the incident-to billing requirements are not met. Medicare covers these services at 85 percent of the physician rate.

 2. The provider must furnish the services in the physician's office, patient's home or an institutional office setting. The term "institutional office setting" describes a location where a physician leases a portion of another institution - such as a room in a hospital - as temporary office space. When an NPP provides care in such a space, you may report it as incident-to.
 
Thanks to the 2002 CMS changes, you can now bill incident-to for hospital visits, such as 99231-99233 (Subsequent hospital care). CMS Transmittal 1775 states that "when a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's unique personal identification number (UPIN)/personal identification number (PIN)." But if no face-to-face contact occurs between the doctor and the patient, even if the physician reviews the records, you should bill the service under the NPP's UPIN/PIN.
 
As a result of the change, your physician assistant (PA), as well as any other NPPs employed by the practice, can now bill an E/M for the morning rounds, if you visit the patient later that day. Incident-to rules, however, require the physician to initiate the plan of care.

 3. The NPP must work under the physician's direct supervision. "This does not mean that the doctor must be in the same room with the NPP," Powe says, "but it does mean that the physician must be physically present in the suite of offices."
 
Some doctors may have offices that connect with a hospital. They may simply walk through a door or hallway to get from one to the other. But if the physician crosses that boundary into the hospital, he can no longer be involved with the patient's care, according to Medicare. Services rendered in their office area at that point cannot be billed as incident-to. Similarly, a physician's availability by phone does not suffice as involvement.

 4. The physician and NPP must share a common employer. The physician and the NPP must be employed by the same practice or, if the physician owns the practice, the NPP must be an employee of that practice.
 
In the event that the practice employs NPPs as independent contractors, the services delivered by the NPPs can't be billed incident-to. HCFA provides one exception to this rule for PAs, who are permitted to form independent groups, subcontract their services to multiple practices, and bill incident-to.

Avoid Denials With 5 Guidelines

 When you report services rendered by NPPs incident- to, follow these simple rules:

 

Let's Look at a Couple of Examples

The following scenarios provide examples of when incident-to can (or cannot) be billed:

Scenario 1: A full-time PA is seeing patients in the practice when the gastroenterologist involved in the patient's care is called away to the hospital. During the physician's absence, the PA performs a follow-up examination with a patient who had undergone a minor procedure a week earlier.
 
Coding solution: You should report this visit directly under the PA's PIN with the appropriate established patient E/M code (99211-99215), unless the service falls within a global surgical period. You cannot bill the PA's services incident-to the physician's because the physician was not present in the office when the visit occurs.
 
Scenario 2: An established patient with hemorrhoids presents for a follow-up examination, and the practice's nurse practitioner (NP) performs an interval history physical exam with appropriate medical decision-making before the patient sees the gastroenterologist. While the NP is conducting the exam, the physician is seeing another patient in the office.
 
Coding solution: In this case, you can report 99213, for instance, as incident-to because the physician has seen the patient previously.

Survive Audits With Solid Documentation

Some reimbursement experts estimate that fewer than 25 percent of incident-to claims filed are in full compliance. Experts recommend that physicians sign NPP charts to document their presence while patients are still in the office. And coders must ensure that the chart indicates the doctor's initial involvement in the patient's care and the development of a treatment plan.