Oncology & Hematology Coding Alert
Check NPP Qualifications Before Reporting Incident-To
Providers must have a valid Medicare PIN Medicare Will Make Most Incident-To Payments Most ancillary staff with the right training may provide incident-to services on behalf of an in-office, supervising physician. This could be a medical assistant (MA), registered nurse (RN), physician assistant (PA), certified nurse specialist (CNS), or nurse practitioner (NP) - among others. No matter who it is, "proper training" for all incident-to service providers stipulates that incident-to providers be enrolled in Medicare with a valid PIN and have a state license. On the claim, you should report 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problems are minimal. Typically, 5 minutes are spent performing or supervising these services) incident-to the physician service. Counseling Can Boost Incident-To E/M Pay close attention to counseling and coordination of care times when reporting incident-to services. If either takes up more than half of the total encounter time, the level of service can be raised. Physician Must Be in the Suite
When one of your office's nonphysician practitioners (NPPs) performs a routine checkup on a long-term cancer patient, you may be able to report the service incident-to the physician, a practice that has myriad benefits for your bottom line.
Oncology offices nationwide value NPPs who can perform incident-to services, because the incident-to rules allow approved NPPs to provide certain services without the physician present - yet still bill them under the physician's personal identification number (PIN).
Benefits: Incident-to providers free up physicians to provide higher-level services to your patients. Also, when an NPP uses the oncologist's PIN to file the claim, Medicare will reimburse fully for the code; if the NPP uses her own PIN, Medicare pays only 85 percent of the code value, says Kimberly Green, CPC, project coordinator at the University of Pittsburgh Physicians.
Follow us for some expert advice on accident-free incident-to coding.
Before you report incident-to services, know that incident-to is a Medicare phenomenon, and private companies may not consider this convention kosher. Most non-Medicare payers do not recognize staff - regardless of credentials - as providers of physician services, experts say.
Best bet: Before reporting NPP services to private carriers, contact the carrier to see how they would like the claim filed.
Many Ancillary Staff Can Provide Services
The work that incident-to service providers perform depends on their area of expertise and the state's scope-of-practice guidelines.
Who does what? MAs and RNs will most likely provide educational services and give injections and infusions; CNSs, NPs and PAs typically perform minor procedures and E/M work.
Example: Let's say your office's RN is seeing an established chemotherapy patient with colon cancer for a checkup. Over the course of a four-minute encounter, the RN:
As long as the patient is not new or undergoing a status change, the RN can oversee the visit and the office can use the physician's PIN when filing with Medicare. Also, you would not report code 99211 on the same day the patient has chemotherapy, based on Medicare regulatory guidelines.
Warning: Never report incident-to services in a hospital setting, says Emily Hill, PA-C, president of the consulting firm Hill & Associates in Wilmington, N.C.
Incident-to "only applies to a physician office practice ... there is nothing called 'incident-to' in a hospital, so it does not apply to the hospital setting," Hill said during a recent teleconference sponsored by The Coding Institute.
Example: The office PA is seeing an established patient undergoing complex radiation treatment for melanoma. The PA spends six minutes performing a physical exam, then notices a note from the physician on the patient's file stating, "Review course of Tx, prognosis with Px at next checkup."
For the next nine minutes, the PA and the patient talk about his course of treatment and the patient's post-treatment prognosis. The PA also sets out the benefits of the patient's current treatment plan.
On this claim, you should report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity). Because the PA was acting at the physician's behest when she counseled the patient, you can bill incident-to the physician.
Why level three? In this case, the PA only performed a level-one evaluation and management service, but the level of E/M service increased to three because more than half the total encounter time was spent counseling the patient. When more than half the total encounter time is spent counseling (or coordinating care), the encounter time is the controlling factor in E/M level.
Because staff qualified to provide incident-to services are doing physician's work, "they can bill based on time spent counseling ... if they meet all the [documentation] requirements; they need to document it just like a physician would," Hill said.
Remember: When raising E/M level based on counseling (or coordination of care), fully document the counseling (or coordination of care) in the patient's record.
Documentation requirements when raising E/M level "are twofold. ... the physician must include a record of the total time of the visit as well as the time spent in the specific counseling or coordination-of-care activities ... and a summary of the content of the counseling," according to CPT Assistant, August 2004.
Obviously, the oncologist does not have to physically see the patient in order for an office visit to be billed as incident-to, but he does have to be in the office suite and immediately available for consultation or patient emergencies, should they arise.
Note: For information about recent updates to incident-to rules, see "Incident-To in the News: CMS Loosens Physician Rules".
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