Gastroenterology Coding Alert

Bill “incident-to” for a previously established problem.

Just how updated are you when it comes to reporting incident-to services? Medicare pays providers for incident-to services that are performed by support staff as if the practitioner personally furnished the service. 

“The ancillary personnel allow medical practices to add types of services for patients with levels of reimbursement sufficient to provide adequate compensation,” says Michael Weinstein, MD, former representative of the AMA’s CPT® Advisory Panel.

However, with the 2016 fee schedule update, CMS also brought forth some critical rules for incident-to billing. As per the applicable state law, providers such as clinical psychologists, PAs, NPs, clinical nurse specialists, and certified nurse midwives are also eligible to bill incident-to services and supplies provided by auxiliary personnel under physician supervision (See 42 CFR §§ 410.71(a)(2), 410.74(b), 410.75(d), 410.76(d) 410.77(c)). 

2016 Changes the Way You Get Paid for These Services

You may claim for incident-to services, provided the encounter is with an established patient, seen within that practice with a previously established problem. In this case, you may get a complete 100 percent reimbursement by CMS.

CMS made two changes in the federal register, 42 CFR 410.26, effective Jan. 1, 2016, clarifying Medicare’s Part B incident-to billing rule.

1) Inclusion of auxiliary personnel: The first change is about the term “auxiliary personnel.” The final CY 2016 Medicare payment rule precisely mentions that auxiliary personnel must not be excluded from Medicare, Medicaid, or any other Federal health program. This new language explains in detail what is already there as a Medicare billing requirement.

“Auxiliary personnel” would means any individual performing under the supervision of a physician (or other practitioner) and they could be employees, leased employees, or independent contractors (42 CFR 410.26(a)(1)). Auxiliary personnel must however abide by the applicable state law, including licensure, so as to make him eligible for rendering the service.

2) Supervision of auxiliary personnel: It is not necessary for the physician who initiated treatment or referred the patient for an incident-to service to supervise for the service. Same goes for billing incident-to services. 

CMS explains: “Billing practitioners should have a personal role in, and responsibility for, furnishing services for which they are billing and receiving payment as an incident to their own professional service.” 

Therefore, the supervising physician need not be the same as the treatment initiating, ordering, or referring physician. However, only the supervising physician/ provider can bill for incident-to services and supplies that have been provided by auxiliary personnel (See 42 C.F.R. § 410.26 and 42 CFR 410(b)(7)).

Example: A patient’s physician sends him another medical expert, and there, he receives services from auxiliary personnel under the supervision of the medical expert. In this case, only the second provider, and not the original referring physician, is permitted to bill incident-to services. CMS is of the opinion that “the physician or other practitioner directly supervising the incident-to service assumes responsibility and accountability for the care of the patient that is provided by auxiliary personnel.”

Clear Up the Direct Supervision Confusion

The term “direct supervision” has been not been very clear to providers, as is evident from their usage of the term to mean differently in different scenarios. As far as incident-to billing is concerned, direct supervision means that the physician (or other provider) needs to be available within in the office suite, readily approachable, even though she is not there in the same room with the patient. As per the Federal Register, the supervising physician also must be immediately available to assist the non-physician provider rendering the service if needed (42 CFR 410.32(b)(3)(ii)).

Exceptions to the rule: Exceptions to this rule are the chronic care management services and transitional care management, where a mere general supervision by the clinical staff suffices. A “general supervision,” means that the services are within control of physicians, even though the physician may or may not be in the office (See 42 CFR § 410.32 (b) (3)).

Know What Goes In Incident-to Billing

In case you are a physician, you can expect to get paid a complete 100 percent of the fee schedule amount for the respective incident-to services billed by you. However, in case this was billed by a nurse practitioner or clinical nurse specialist, one would be paid 85 percent of the fee schedule amount. What’s more, these payments are also subject to the coinsurance amounts and deductibles. 

Furthermore, according to Medicare, you can bill only the services and supplies commonly provided in physicians’ offices free of cost; or included in a physician’s charge — as incident-to. You may not bill services having their own Medicare benefit category, for example diagnostic X-ray services, as incident-to services. 

Final takeaway: “With increasing attention being paid to patient engagement, education, and outcomes the gastroenterology practice may find that it is more effective to use auxiliary personnel to assist in the overall care plan,” feels Weinstein. That said, however, in order to reap the most out of our support staff work we still need to wait as CMS comes up with a future guidance on these services, as well as a listing of services appropriate for incident-to billing.