Medicare Compliance & Reimbursement

Tip: Your documentation defines the type of service provided.

With physicians on vacation, holiday, or summer sabbatical, juggling clinical care can be a hassle, and it’s easy to forget to adjust your billing habits. Unfortunately, some practices continue to bill incident-to even when the doctor is out of town — and that’s a violation.

Background: When a physician and a non-physician practitioner (NPP) work together to provide an evaluation and management (E/M) service, the situation could be considered either an incident-to service or split/shared visit. Billing a service incident-to requires you to follow well-defined regulations, and it is important to keep in mind that not all services will qualify.

Remember: Income is lost every time you miss a service that qualifies for incident-to; moreover, you invite trouble every time you bill one that does not.

Important: Medicare, and other payers that follow Medicare’s guidelines, are the only payers who follow incident-to and split/shared visit rules.

Know the Basics of Incident-to Services

“Incident-to billing is a Medicare benefit that allows a physician practice to bill for services personally provided by ancillary staff under the name and NPI [national provider identifier] of the supervising physician or non-physician practitioner [NPP],” explains Jean Acevedo, LHRM, CPC, CHC, CENTC, president and senior consultant with Acevedo Consulting Incorporated in Delray Beach, Florida.

Tip: When you use incident-to correctly, “it can add 15 percent to a practice’s bottom line when a nurse practitioner, physician assistant, or clinical nurse specialist — an NPP — performs a service,” Acevedo says.

Official definition: MLN^® Matters SE0441 defines incident-to services as “services that are furnished incident-to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home.”

According to MLN^® Matters SE0441, other characteristics of incident-to services include:

• The physician must perform incident-to services in the office as an integral part of the patient’s normal course of treatment that the physician planned when he personally performed the initial service.
• The physician must remain actively involved in the patient’s course of treatment.
• The physician must be present in the office suite to offer assistance, if needed.
• The physician must bill the incident-to service under his ID or to whatever other legal entity that bills for the service.

Direct supervision: Under incident-to rules, the physician is in charge of the patient, and the non-physician practitioner is acting as a physician extender as opposed to acting under their own license, said WPS Medicare’s Ellen Berra during the MAC’s “Incident to and Shared/Split Services Question and Answer Teleconference.” The services must be provided under direct supervision and the physician should be immediately available should the need arrives, meaning the supervising physician is in the office suite, or “within speaking loudly distance,” she said.

“Not within ‘shouting distance,’ not just available by telephone or by walkie talkie, not on a different floor — but really within that designated office space.”

Relationship requirements: The person providing the incident-to services must have an employment relationship either with the physician or with the group that employs the physician, Berra added. “It can be a direct employee, a leased employee, a contracted employee — but it does have to have that relationship with the entity that’s employing the physician or be employed by the physician himself,” she said.

Take a Look at Split/Shared

Unfortunately, the split/shared billing category is a very confusing one in relation to understanding incident-to, and an area of concern for billers. Practices often improperly code this or lack both the supervising physician’s and NPP’s medical notes, showing both providers were part of the visit. Detailed documentation is essential to avoid a denied claim and loss of payment.

Nuts and bolts: A split/shared E/M visit is “a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service,” according to the Medicare Claims Processing Manual.

Other characteristics of split/shared visits E/M include the following, per the Medicare Claims Processing Manual:

• The split/shared visit must involve all or some portion of the history, exam, or medical decision making components of an E/M service.
• The physician and NPP must be in the same group practice or work for the same employer.
• Only report a split/shared E/M visit to selected E/M visits and settings such as hospital-based encounters like the inpatient, observation, and ED. You can also report split/shared for services that take place in hospital outpatient departments or provider-based clinics.
• Split/shared visits are not appropriate for critical care services, consultation services, new patient office visits, or in the skilled nursing facility/nursing facility settings.

Reminder: As always, the medical documentation should support all of the criteria for an incident-to or a split/shared service. “Incident-to” services don’t require two notes; shared/split visits do.