Medicare Compliance & Reimbursement

100 percent pay is possible if NPP follows physician's plan of care.

If you do not consider billing "incident to" the physician when a qualified nonphysician practitioner (NPP) performs services for Medicare patients, you are letting deserved reimbursement fly out the door.

Bottom line: When you bill incident-to, you garner 15 percent more per service than if you bill under the NPP's national provider identifier (NPI). Incident-to coding does have some strict rules, though. To ensure that all your incident-to claims are on target, answer these questions before billing.

To qualify for incident-to billing, the internist must see the Medicare patient during the initial visit and establish a clear plan of care, reported Sharlene Scott, CPC, CPC-H, CCS-P, CCP-P, PMCC, during a presentation at The Coding Institute's multispecialty conference in Orlando, Fla. (www.codinginstitute.com).

If the NPP is treating a new problem for the patient, or if the internist has not established a care plan for the patient, then you cannot report the visit incident-to.

Example: An established Medicare patient reports to the physician on Dec. 13. The doctor performs an E/M service, diagnoses the patient with pneumonia, and writes prescriptions. On Dec. 21, the patient returns to the doctor for a follow-up visit. The NPP checks the patient's vitals and asks her if the medication is causing any side effects.

In this example, you can report the NPP's service incident to the physician. On the claim, report the appropriate level E/M code.

Important: You must file the claim under the supervising internist's NPI rather than the NPP's NPI; this ensures you 100 percent pay for the E/M, while coding under the NPP's NPI results in an 85 percent pay for the service.

Remember: The NPP's visit can be reported incident to the physician in this instance -- as long as the NPP is qualified to provide the service and the encounter meets pre-specified supervision requirements.

You must also be sure that the NPP has the proper credentials to perform incident-to services, stressed Scott, an instructor with Coding Academy of America/American Coding Centers in Baltimore.

The NPP could be a physician assistant (PA), nurse practitioner (NP), clinical nurse specialist, or certified nurse midwife -- as long as the NPP meets state and federal guidelines to report incident-to. 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 regulations for NPP qualifications. If the NPP does not meet one or both sets of guidelines, don't bill incident-to for his or her services.

According to Medicare, a physician must provide "direct supervision" to bill a service incident-to, relays Chris Felthauser, CPC, CPC-H, ACS-OH, ACS-OR, PMCC, medical coding instructor for Orion Medical Services in Eugene, Ore. "A supervising physician must be immediately available in the office suite ... just because he is 'somewhere in the building' does not mean he is immediately available," he stresses.

"The MD does not have to be in the exam room with the NPP, but he must be available to render assistance if necessary," explains Anna Rosario, CPC, compliance auditor with Harvard Medical Faculty Group at Beth Israel Deaconess Medical Center.

The supervising physician does not necessarily need to be the same physician that established the patient's care plan, Scott reminded.

Though it is not required (yet), experts recommend that the internist who establishes the care plan include a note approving NPP involvement in the patient's care. That way, the patient's record will "reflect the physician's active participation in the management of the patient's course of treatment," explained Scott.

Example: During the initial visit to treat a patient's hypertension, the physician includes a note stating: "Established care plan for patient's hypertension; visits to NPP for follow-up care approved."

Tell your physicians to get in the habit of writing these linkage notes, because down the road this step will likely be required, says Rosario.

"One of the items on the Office of Inspector General (OIG) 2009 work plan includes 'Review of Physicians' Medicare Services Performed by Nonphysicians.' The OIG will examine qualifications of nonphysician staff that perform incident-to services, and determine whether those qualifications are consistent with the recognized standard of care," Rosario explains.

The bottom line: You don't have to let your valuable and hard-earned reimbursement slip through your fingers. Be sure to follow this advice the next time a qualified NPP performs services for your Medicare patients.