Ob-Gyn Coding Alert

The "incident to" rule for nonphysician practitioners (NPPs) can prove challenging to coders for ob/gyn practices, where nurse practitioners (NPs), physician assistants (PAs) and midwives provide so much patient care. A thorough understanding of the incident to rules is critical not only for obtaining proper reimbursement but also for avoiding serious allegations of fraud and even malpractice.
 
Medicare developed the incident to concept to monitor the activities of NPPs, whom the physician hires and who bill under the physician's provider identification number (PIN). Direct billing for NPP services yields 85 percent reimbursement from Medicare; incident to billing for the same services yields 100 percent reimbursement.
 
Although all carriers have some reimbursement policy for NPPs, Medicare is the only carrier to which the CMS incident to rule applies. "The biggest misunderstanding coders and even insurance companies have about incident to is that they think the CMS rules apply in all situations when, in fact, they apply to Medicare only," says Joan Slager, CNM, MSN, director of nurse-midwifery at Bronson Women's Service in Kalamazoo, Mich., and a member of the Division of Standards and Practice of the American College of Nurse-Midwives.
 
 "Apart from that, each carrier has its own rules." An understanding of Medicare's incident to rules is a good starting point for private payers who must realize that policies are not universal.
 
CMS rules on NPPs are stricter than many non-Medicare payers' rules on NPPs; thus, applying CMS rules without first gaining a clear understanding of the non-Medicare payers' rules could mean lost revenue to  your practice. "If the practice and the insurance company have not mutually defined what they mean by incident to in their unique relationship," says Slager, who is also a lecturer on incident to billing, "the CMS rules may be used due to failure of developing any other documentation. It is not illegal for the insurance companies to impose these rules, but it may not be in the best interest of the practice nor reflect what the practice does in terms of the relationship between physicians and NPPs." However, if the practice does not create its own definition for incident to in the payer contract, it could be guilty of fraud if CMS guidelines are not met and the payer adopts the CMS guidelines at some point.
Medicare's Rules
Medicare's rules for incident to billing generate some of the most difficult questions for ob/gyn coders. Discussing each rule can help alleviate any coding confusion:
 
1. The physician must see new patients during their first visit, as well as established patients presenting with new problems during their first visit for the new problems. Medicare insists that the physician handle the initial encounter in these cases because he or she [...]