Oncology & Hematology Coding Alert

Incident-to billing may very well be your oncology practice's reimbursement nightmare before Christmas. If you have a carrier that has been imposing unfair interpretations of the rules or if your practice is fuzzy on the concept, recent clarification from CMS may expand your practice's opportunities.

CMS may be trying to clear up issues resulting from complaints that some carriers are setting arbitrary interpretations of the incident-to rules, says Susan Callaway Stradley, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C. She has heard carriers argue that if a nonphysician practitioner (NPP) sees the patient, regardless of what is done and/or documented by the physician, the service must be billed under the NPP's provider identification number (PIN). That's simply not the case.

While the incident-to rules remain substantially the same, clear-cut scenarios for applying them in office/clinic settings and hospital inpatient, outpatient and ED settings are now inscribed in the Medicare Carriers Manual.

Transmittal 1776 (Oct. 25, 2002) clarifies the MCM on the split-billing issue. It dictates that in the office or clinic setting, an E/M service that is split or shared between a physician and a nonphysician practitioner will be considered "incident-to" if the requirements for incident-to are met (see Fed. Reg. SS 2050.1, 2050.2 and 15505 subsection G) and the patient is an established patient.

Oncology billers especially must never lose sight of the "established patient" requirement because an established patient with a new problem a scenario not uncommon during chemotherapy is treated like a new patient under incident-to billing, says Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett. "Established patient" still means an established patient with an established problem.

For example, if an NPP or a PA performs a portion of an E/M encounter and the oncologist completes the service, then the service should be reported under the doctor's PIN. If the incident-to requirements are not met because, for instance, the oncologist was called away on an emergency while the patient was in the office, the service must be reported using the NPP's PIN.

In other settings, including hospital inpatient and outpatient settings, an E/M service shared between a physician and an NPP from the same group practice may be billed under either the doctor's or the NPP's PIN as long as the doctor provided some face-to-face portion of service.

Consider this example: An NPP sees a hospital inpatient in the morning, and the oncologist sees the same patient face-to-face in the afternoon. In this case, the doctor or the NPP may report the service. However, if the doctor reviews an outpatient's medical chart without seeing the patient, the NPP must bill the service under his or her PIN.

While this memo clarifies that you can bill a shared service under the physician's name, you've always been able to do that, as long as the physician's involvement and documentation support the service, Callaway says.

Transmittal 1776 is a welcome clarification of the earlier CMS rule, Towle says. She explains that the former CMS rule held that if an NPP and a physician each see the same patient in the same encounter and each performs a part of the visit, then in order to bill for the entire visit, practices must submit two claims with the E/M unlisted procedure code 99499 and two sets of documentation for the service. "That burdensome requirement is now gone."

Now, the only time a physician or an NPP would use code 99499 (Unlisted evaluation and management service) would be in the rare circumstance when the physician or NPP provides a service that does not reflect a CPT code description. A description of the service provided must accompany the claim.