Internal Medicine Coding Alert

Question: Is there any circumstance in which a group can bill all services and all providers (including other physicians) under just the head doctor? I know we can bill NPP services incident-to another physician, but what about other physicians?

Wisconsin Subscriber

Answer: No, you cannot always bill services for all providers under one of the group's medical doctors. One reason is because you may not bill one doctor incident-to another doctor. Incident-to rules don't apply here because they pertain to the relationship between a physician and a nonphysician practitioner (NPP).

Bottom line: It is never acceptable to bill services provided by one physician under another physician's name or national provider identifier (NPI). Billing under the name of a physician who did not perform the service can lead to problems including allegations of false claims submissions.

You can, however, report NPP services incident to the medical director if the visits meet all the requirements of incident-to services. The NPP could be a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist -- as long as the NPP meets state and federal guidelines to provide the service. The NPP must be "licensed by the state under various programs to assist or act in the place of the physician," according to the Medicare Benefit Policy Manual, Chapter 15.

Best bet: Check your state and local Medicare Audit Contractor's (MAC) or Medicare Carrier's regulations for NPP qualifications. If the NPP does not meet one or both sets of guidelines, don't bill incident-to for physician level services (such as 99212-99215, Office or other outpatient visit ...).

For more on incident-to billing, refer to the Medicare Benefit Policy Manual, Chapter 15, Section 60.2 at www.cms.hhs.gov/Manuals/downloads/bp102c15.pdf.