Medicare Compliance & Reimbursement

Myth 1: When reporting 99211 "incident to" a physician, you should bill it under the name of the physician on record for that patient.

Reality: When a service such as a nurse visit (99211, Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of the physician) is billed incident to the physician, make sure you file the claim under the supervising physician's name. The OIG recently found that many practices are billing incident to services under a physician's name who was not on the premises during the encounter.

Often, practice management systems use the physician of record rather than the supervising physician when billing services. This arrangement makes allotting finances between physicians easier, but it causes incident to criteria to appear to be unmet. "Incident to" requires that the supervising physician is directly available, generally considered to be in or immediately adjacent to the office suite.

Myth 2: If a patient has symptoms of a particular illness, you can count that information toward both the history of present illness (HPI) and review of systems (ROS).

Reality: You can't "double dip" and count the same information toward two separate elements.

Example: If the patient suffered a sprain or fracture, the doctor would typically address the musculoskeletal system during a ROS. Examples of a musculoskeletalROS might include symptoms such as poor range of motion, joint pain, dislocation, or muscle stiffness, among others. These can be counted as elements of HPI, or ROS, but cannot be double-counted to support both elements.

Myth 3: If the physician sees a patient in the intensive care unit (ICU), he should always report his services using critical care codes (99291-99292).

Reality: You can't automatically bill critical care simply because the place of service is the intensive care unit (ICU). If your physician evaluates a new patient in the ICU but does not perform critical care services, you'll report an initial hospital care code such as 99221 (Initial hospital care, per day, for the evaluation and management of a patient ...).

Critical distinction: Critical care is not location-based; rather, it describes a specific kind of care. You must meet the following criteria to bill for critical care:

• The patient must have a critical illness (usually defined as a critical organ system failure or a shocklike syndrome)
• The physician must document at least 30 minutes of time spent directly with the patient or on the floor (hospital unit) limited only for that patient
• The physician must document highly complex decision making to assess, manipulate, and support vital system function(s) to treat the critical illness or prevent further deterioration of the patient's condition.

Typically, the physician providing critical care monitors the patient for an extended time and obtains opinions and advice from multiple specialties to create an overall care plan.