Medicare Compliance & Reimbursement

Question: We recently hired a nurse practitioner and aren't sure which modifier we should append to our claim to report our services as "incident-to." Can you please advise?

Answer: Although Medicare carriers have strict guidelines for reporting incident-to services, using a modifier is not one of them. Neither CPT nor HCPCS features a specific modifier that applies to incident-to billing for Medicare patients.

Correctly billing your nonphysician practitioners' (NPP's) incident-to services means the difference between 85 and 100 percent reimbursement. But if you bill incident-to haphazardly, you could be inviting auditors' scrutiny.

Your first step in collecting for your incident-to claims is determining whether the services involved direct supervision. This means that the physician must be in the immediate office suite while the NPP is performing the incident-to services.

You don't want to get caught using the term "direct" too loosely. Having the physician available by phone or having the physician somewhere on the grounds in a large facility is not acceptable. And you may want to check your state's practice requirements to see if your state mandates stricter supervision requirements than Medicare.

Good idea: Keep physicians' work schedules on file to prove they were present when incident-to services occurred. And some carriers like to see the name of the supervising physician in the progress notes -- especially if it is a different physician than the one who wrote the plan of care.

Also, keep in mind that incident-to services "...must be part of [the physician's] normal course of treatment during which a physician personally performed an initial service and remains actively involved in the course of the treatment," states Medlearn Matters article SE0441.

This means that incident-to billing works only with an established patient following a plan of care.

Remember: As of November 2004, the supervising physician can be different from the one who actually wrote the plan of care. Important: The reimbursement must go to the physician who supervised the incident-to services that day.

Beware: An established patient with a plan of care who comes in for a new, unrelated condition is not an appropriate case to bill incident-to.

Tip: The physician should document in his plan of care that the patient will follow up with the NPP for monitoring of that particular episode of care. That care could be for managing diabetes mellitus, hypertension, coronary artery disease or other conditions.

When there is a new problem, however, the physician must see the patient and modify the plan of care for the NPP to follow accordingly.