Master the rules of this OIG hot button
Don't let the tricky nature of -incident-to- claims keep you from getting 100 percent reimbursement when you deserve it. We-ll take you step-by-step through a typical case so you can master this complex coding convention.
The basic concept: Auxiliary personnel (nurses, technicians, etc.) provide incident-to services under a physician's -direct supervision,- which in the office setting means the physician is immediately available in the office suite during the service. Here's the Payoff When a nonphysician practitioner (NPP) performs a service incident-to a physician's service, you may report the claim under the physician's Medicare number and secure 100 percent reimbursement.
If the NPP's services are not provided incident-to the physician, however, you must bill under the NPP's number, which will garner you 85 percent reimbursement for the same service.
Important: Your medical record needs to reflect that the incident-to services are an integral part of the patient's plan of care or treatment course.
The supervising physician can be different from the one who actually wrote the plan of care, but the reimbursement should go to the physician who supervised the incident-to services that day. Beware of Restrictions You should not report a service incident-to if an established patient with a plan of care comes in for a new, unrelated condition, says Barbara J. Cobuzzi, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.
An NPP -- an NP, PA, clinical nurse specialist (CNS), or a certified nurse midwife (CNM) -- can still see an established patient with a new problem for 85 percent reimbursement. But you must report the services under the mid-level provider's own Medicare number -- not the physician-s, Cobuzzi says.
Note: For more on incident-to rules, see the article -Are You Reporting the Wrong Services as Incident-to?- in this issue.
Put Your Know-How Into Practice Here is a walk-through of how to report a typical oncology incident-to service to Medicare:
-In the physician office-based setting, you will often see 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) provided by qualified nursing personnel, under the direct supervision of a physician,- says Ohio-based coding consultant Linda Templeton, CPC, CPC-H, who managed an oncology practice and chemotherapy infusion center for five years.
Remember: Direct supervision means that the physician -is present within the office suite and immediately available to furnish assistance and direction,- Templeton says. Use CMS- Instructions CMS offers instructions on reporting incident-to services on the CMS-1500 form in CMS Transmittal 148 dated April 23, 2004 (
www.cms.hhs.gov/transmittals/downloads/R148CP.pdf), Templeton says. You-ll also find them in the CMS-1500 completion guidelines at
www.cms.hhs.gov/manuals/downloads/clm104c26.pdf.
The instructions tell you:
- For services incident-to a physician or NPP service, place the name and [...]
