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 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 is responsible for developing the treatment plan.
 
A physician would code the initial visit with a new patient who is eligible for Medicare using the 99201-99205 series (office or other outpatient visit for the E/M of a new patient).
 
A physician would code the initial visit with an established patient presenting with a new problem who is eligible for Medicare using the 99211-99215 series (office or other outpatient visit for the E/M of an established patient).
 
2. The NPP can administer subsequent visits, including screening examinations and sick patient visits, billing at 100 percent of the Physician Fee Schedule.
 
Once a new patient is established with the practice, the NPP can perform her routine pelvic screening and breast exam (once every one or two years, depending on her risk category). The visit is coded G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) and Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) and billed under the physician's provider number. Using this method, the practice can bill for 100 percent of the physician's fee for the service.
 
If the physician treated the patient for the new problem and had the patient return for either an ultrasound or other follow-up care, an NPP can administer both the ultrasound and the follow-up care and bill under the physician's provider number.
 
3. During any visits with the NPP, a physician who is a member of the practice must be physically present in the office while care is rendered.
 
This is a point of contention among many physicians. Medicare considers "in the office" to mean in the suite of offices and relatively close to the examination area where the NPP is treating the patient. Although there is no exact definition of what constitutes "in the office," coders and physicians should use common sense when making the determination. Doing rounds in the hospital to which the office is connected is not considered "en suite." Visiting other patients in a nursing home while the NPP conducts a Pap and pelvic in the same facility does not qualify.
 
Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C., advises coders using incident to billing to make certain that there is documentation that proves the physician under whose provider number NPP services are billed was actually there. "The practice should retain old schedules and be able to show documentation of other patients who were seen by the physician at the same time as the NPP encounters," says Callaway. The likelihood is that the practice will never need to submit this information; however, it is essential that this evidence be on hand in the event of a Medicare audit.
 
4. Incident to billing cannot be used for hospital inpatient billing.
 
Physicians cannot send NPPs to do their work on hospital patients nor can they have an NPP accompany them to the hospital and treat patients simultaneous to their visiting with other patients. If these criteria aren't met, the NPP must bill Medicare using his or her PIN and will receive payment at 65-85 percent of the physician payment.
 
Note: Medicare's rules on incident to billing can be found in Medicare Carriers Manual section 2051 or at www.hcfa.gov/pubforms/14_car/3b2049.htm#_1_7.

Scenario 1. A resident sees a Medicare patient who reports to the ER with postmenopausal bleeding. The resident initiates a chart, examines the patient and admits her for observation. He reports his finding to the attending physician, who initializes a treatment plan and admits her to the hospital for observation. Can the resident's services be billed as incident to?
 
Incident to rules never apply to residents on an inpatient or outpatient basis and can never be billed for service in a hospital. Instead, CMS rules for teaching hospitals apply where residents see patients under the supervision of attending or teaching physicians.
 
Scenario 2. The practice physician is out of the country, and has another physician seeing patients in the office during his absence. The NP also treats patients while the practice physician is away. Should the covering physician sign off on the patients treated by the NP (and therefore those services are billed as incident to) or should the NP directly bill to Medicare?
 
The NP can still bill incident to. Although the physician under whose personal identification number the NP normally bills is away, CMS guidelines do not address "signing off" issues. The important part is that a physician be present in the office suite when the NP is rendering care. The bill should be sent in the name of the physician who is on record as present.
 
Scenario 3. Patient A, an established Medicare patient, is scheduled with her ob/gyn for a follow-up examination to check the status of uterine prolapse. At the time of her appointment, patient B presents at the office with an emergency that must be treated immediately. The physician treats patient B, and patient A is seen by the on-staff PA. The PA examines the patient, notes that her symptoms have improved, arranges for an additional follow-up visit in three weeks and codes from the 99211-99215 series under the incident to rule. Is this correct?
 
Yes. Although patient A was originally scheduled to be seen by the physician, she is an established patient with an established problem. Her encounter with the PA falls within Medicare's guidelines. Since the physician is still physically present in the office suite, the rules for incident to are met.

Alleging overuse of the incident to rule, CMS has been insinuating for some time that it will do away with incident to billing. The result would be NPPs billing under their own provider numbers at a reimbursement rate lower than that of physicians. Even for practices that do not treat many Medicare patients, the result of this change could be dramatic since many third-party payers tend to follow CMS's lead when setting reimbursement policy.