Neurology & Pain Management Coding Alert

Because the U.S. Office of Inspector General (OIG) intends to scrutinize consolidated billing in 2003, neurology practices must submit technical component claims (modifier -TC) directly to skilled nursing facilities (SNFs) not to Medicare for their SNF patients.

The Balanced Budget Act of 1997 requires SNFs to consolidate billing for Medicare Part A residents, meaning that physicians who perform in-office procedures such as electromyograms (EMGs, 95860-95872) on SNF patients must bill the technical component of the service to the SNF.

When an SNF calls your practice to schedule a procedure, the receptionist should indicate on the patient's fee ticket that he or she resides in an SNF.

"When the fee ticket gets to the coder, they should create another, separate fee ticket," recommends Deb Hudson, CCS-P, coder at the Mason City Clinic, a 30-physician multispecialty practice in Iowa. "The fee ticket for professional services will go to the patient's Medicare Part B carrier, and the other fee ticket, for technical services, is billed to the SNF with modifier -TC [Technical component]." Hudson suggests setting up separate accounts for the various SNFs in your area so coders can send the information to the appropriate party at the nursing facility.

Remember that you may bill a procedure's technical component only if your practice owns the equipment (x-ray, EMG, etc.) and pays the salaries of the personnel taking the films: The -TC modifier's fee includes those technical costs.

Consolidated billing rules also apply to physical, occupational and speech therapy services furnished to SNF residents covered under a Part B stay. These therapies are the only Part B services included in SNF consolidated-billing regulations. You can still bill Medicare directly for SNF patients' E/M visits, however.

Medicare defines incident-to services as those provided by a nonphysician practitioner (NPP) and which are an integral part of the physician's personal professional services in the course of a diagnosis or treatment of an injury or illness, says Ron Nelson, PA-C, reimbursement policy analyst, president of Health Services Associates Inc., a family practice in Fremont, Mich., and past president of the American Academy of Physician Assistants. Report services provided incident-to using the appropriate CPT codes under the supervising physician's personal identification number (PIN). Payers should reimburse such services at the full fee schedule amount.

There are four main guidelines for billing incident-to, as outlined in section 2050 of the Medicare Carriers Manual (MCM). The NPP providing incident-to services need not be licensed under state law as long as the following requirements are met:

The physician must be involved: The physician must see all patients to establish diagnoses and/or a treatment plan. Although the NPP may provide subsequent services as determined by the physician, he or she may not provide initial care, Nelson warns. Nor may the NPP see patients on his or her own. The physician must always be involved in patient care, and any services or procedures billed incident-to must be those typically provided under the physician's PIN.

The NPP must be under the physician's "direct supervision": This second requirement relates to the first and specifies that coverage of services incident-to the physician's services "is limited to situations where there is direct personal physician supervision," according to the MCM. As defined by the MCM and reaffirmed by CMS Program Memorandum B-01-28 (April 19, 2001), direct supervision does not mean that the physician must be present in the same room with the NPP, but he or she must be present in the office suite and immediately available (in person, not via telephone) to provide assistance and direction to the NPP.

Incident-to services must be provided in the physician office, institutional office setting or patient's home: Do not report incident-to services in the hospital. For instance, if the NPP assists the physician in making hospital rounds, do not report his or her services incident-to. An "institutional office setting" is a location leased by the physician within another institution (i.e., a nursing home or rehabilitation center) as a temporary office space.

Note: Effective Oct. 25, 2002, CMS will allow incident-to billing for hospital inpatient, outpatient and emergency department evaluations when both a physician and a nonphysician practitioner (NPP) see the patient. For more information, go to the CMS Web site: http://www.cms.hhs.gov/manuals/pm_trans/R1776B3.pdf.

The NPP must by employed by the physician or by the physician's employer: According to the MCM, to bill incident-to, the NPP performing the service must be a "part-time, full-time or leased employee of the supervising physician, physician group practice or of the legal entity that employs the physician who provides direct personal supervision." You cannot claim services provided by NPPs not employed by the physician or group practice, even if the services are provided on the physician's orders, Nelson says.

To demonstrate that you have met these four requirements, documentation supporting the incident-to services must clearly link the NPP to the supervising physician. This could include the physician's signature on all notes or charts, notation from the supervising physician proving that he or she saw the patient initially, and notes from additional dates of service (other than those requested) showing physician involvement. Always note the supervising physician's presence in the office suite.

For instance, an NPP may perform pain-pump maintenance, such as filling and port flushing, under incident-to guidelines. For this minor service, the NPP reports 99211 (Office or other outpatient visit for the evaluation and management of an established patient) and documents the date of service, vital signs (if taken), the service provided, and his or her signature. The NPP should also note the surgeon's presence in the office suite, and the physician may initial the documentation to attest further to his or her presence.