Medicare Compliance & Reimbursement

How it works: When an NPP provides a service to a Medicare patient incident-to the physician, you can report the service under the physician's national provider identifier (NPI) as long as all of the Medicare rules for incident-to services are followed. Doing so will net 100 percent pay for the service. When you bill for the NPP's service under the NPP's own NPI, however, you'll receive 85 percent of the full rate. Be on the lookout for incident-to billing opportunities and ensure you're up to speed on the rules, or you could be shorting your practice on deserved reimbursement.

You can bill incident-to the physician only when the NPP treats an established Medicare patient with a plan of care (POC) in place. The POC must also be the reason for the encounter. If the NPP addresses a new problem during the visit, or if the physician has not previously established a care plan for the patient, then you cannot bill as incident-to.

To qualify for incident-to billing, the physician must see the patient during an initial visit and establish a clear POC. If a patient comes in with a new problem, the NPP can see the patient, but must bill under her own NPI -- and you'll only receive 85 percent of the service's fee.

The physician should document in the POC that the patient will follow up with the NPP for monitoring of that particular encounter. Qualifying care could be for hypertension, diabetes, cancer, or other medical conditions. When there is a new problem, however, the physician must see the patient and modify the plan of care before the NPP can provide follow-up care and bill the services as incident-to the physician.

Example: The NPP provides a level-three E/M service to an established Medicare patient with a plan of care (POC) in place for his/her hypertension. The visit is a checkup to see how the patient is responding to medication, diet, and other parts of the treatment plan, as well as how s/he might fare with other options. During the encounter, the physician is in his office down the hall seeing other patients. This visit should qualify as incident-to.

Payment key: Since the encounter meets the supervision and POC requirements, you can garner 100 percent pay for this E/M service. Report 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) with 401.0 (Essential hypertension, malignant) appended under the physician's NPI.

Note: The supervising physician under which incidentto care is billed is not necessarily the physician who established the POC. Always bill incident-to services under the supervising physician, even if he is not the physician who wrote the POC.

Example: An NP is treating a patient's thyroid problem, following a plan of care laid out by doctor A. The  supervising physician, however, is doctor B, and doctor A is out of the office. You can still bill the visit incident-to, using doctor B's NPI since he supervised the encounter.