Neurology & Pain Management Coding Alert

Tip: Start by recognizing what constitutes incident-to circumstances.

Billing Medicare for incident-to for services your non-physician practitioners (NPPs) provide can help you collect the entire assigned physician fee for your NPP – if you handle things correctly. Let our answers to three top incident-to questions help you keep on the right track. 

Question 1: What Is Incident-To Billing?

“Incident-to” is the term for services that the NPP provides under a supervising physician’s authority and billed under the supervising physician’s NPI (national provider identification) number).  It’s one way to bill services to Medicare. 

Before billing incident-to, you must meet several criteria set forth by CMS: 

• The service is furnished by an NPP as an expense of the practice (the NPP can be an employee, leased employee, independent contractor of the practice, etc.). 
• The treatment plan is initiated by the physician. The NPP can provide care once the plan is established and the physician remains active in the patient’s care and management. 
• The service is provided under the physician’s direct personal supervision. 
• The NPP performs the service within the scope of her practice and in accordance with state law.
• The service can be categorized as one that is commonly furnished in the physician’s office or clinic (not in a facility setting). 

Note: The NPP cannot bill incident-to for evaluation of a new patient. Incident-to also does not apply when the NPP sees an established patient for a new problem or when an established patient has a change in his treatment or plan of care. 

Private payers:  The above rules are set out by Medicare, but some private payers follow the same guidelines when creating their own incident-to criteria. Cigna’s policy, for example, states, “For services to be considered as incident to a physician’s professional service, 1) they must be rendered under the physician’s immediate personal supervision by his/her employee, 2) they must be an integral, although incidental part of a covered physician’s service, 3) they must be of kinds commonly furnished in physician’s offices, and 4) the services of non-physicians must be included on the physician’s bills.”  

Important: Make sure you get from your private payers and your other non Medicare payers, such as Medicaid what their rules are for NPP billing and incident to services in writing to assure that you are providing following exactly what they expect from your practice. For example, Kansas Medicaid does not allow incident to billing for NPP services and they require the NPPs bill directly under their own NPI.  Kansas Medicaid allows 75% of their fee schedule for NPP services.  

Remember: Physicians cannot bill incident-to another physician because you cannot bill services provided by one physician under another physician’s name or number. Billing under the name of a physician who did not perform the service could lead to allegations of false claims submissions. 

Question 2: What Qualifies as ‘Direct Supervision’?

In terms of incident-to, the physician whose name and NPI will be used for billing must be physically present in the office suite and immediately available to provide assistance and direction as necessary. The physician providing the direct supervision, the physician you bill under, however, might not always be the patient’s regular physician or the physician who developed the problem’s initial plan of care.

Scenario: Dr. A saw Mrs. Jones and established a plan of care for ongoing treatment of her chronic back pain (338.29). She returns for her follow-up visit in two weeks. She sees the nurse practitioner, who continues the planned treatment. Dr. A is at the hospital performing pain management procedures that day and his partner, Dr. B, is the in-office physician. You would bill the visit as incident-to under Dr. B’s name and NPI since he was physically present and able to provide direct supervision.  If you billed under Dr. A., it would be considered fraud (billing for services not provided) because Dr. A did not provide direct supervision of the NPP when the services were provided to Mrs. Jones. So, even though Mrs. Jones received the service, she did not receive it from Dr. A, and as such, billing under Dr. A is considered fraudulent Medicare billing.

Question 3: What Kind of Documentation Is Needed? 

The more detailed your documentation related to incident-to services can be, the better. Keep these points in mind: 

• Ensure that the documentation clearly notes who performed the service. 
• Even if your claim has the doctor’s number on it, the actual medical record should be signed by the NPP and note that the NPP was the practitioner. 
• Verify that you have proof that a supervising physician was actually on site on the date and time of service. More than one incident to claim has been denied because auditors realized a physician was on vacation while he was purported to be overseeing several NPPs.  Although many practices have proven the physician was present via the schedule for that day, it is highly recommended that NPPs start out incident to notes with the following documentation: “Dr. B was immediately available and provided direct supervision  in the office during the patient visit today.” 
• With this documentation present, there will be no question as to who was present in the office providing direct supervision on the date of service.

Pay out: Billing incident-to has numerous requirements, but can boost your bottom line when done correctly. When the claim meets incident-to criteria, Medicare will reimburse at 100 percent of the Medicare Physician Fee Schedule (MPFS) allowable for that service. If you don’t meet all the incident-to criteria and the NPP bills Medicare directly with his or her own name and NPI on the claim form, the payment is reduced to 85 percent of the MPFS allowable by Medicare.  All non-Medicare payers will have their own reimbursement rules as demonstrated above with Kansas Medicaid.