Oncology & Hematology Coding Alert

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 UPIN of the physician or NPP who performed the initial service and ordered the nonphysician service in items 17 and 17A. When CMS changes the CMS-1500 to allow room for NPIs, 17B will replace item 17 or 17A.

- When the ordering physician or NPP doesn't supervise the incident-to service, enter the supervisor's PIN in 24K. When CMS changes the CMS-1500 to allow room for NPIs, 24J will replace 24K.

- Enter the signature of the supervising physician or NPP (which may or may not be the ordering physician) in item 31.
 
Use of the new CMS-1500 with room for NPIs is mandated on April 2, 2007--that includes rebilling previous claims filed with the old form (read more at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5060.pdf)

Protect Yourself With Proper Documentation

These services are subject to the same documentationrequirements as physician-supervised services.

You must have very clear documentation when reporting incident-to services, showing that you-ve met all requirements.

Keep MLN Matters SE0441 Handy

MLN Matters articles are a great resource for keeping track of incident-to requirements.

Check out www.cms.hhs.gov/MLNMattersArticles/downloads/SE0441.pdf for more on incident-to rules.

This MLN Matters article clarifies that incident-to services must be all of the following:

- an integral part of the patient's treatment course

- commonly rendered without charge (included in your physician's bills)

- of a type commonly furnished in a physician's office or clinic (not in an institutional setting)

- an expense to you (the physician).

Note: CMS says that incident-to services are -commonly furnished in physicians- offices or clinics.-

The only time a hospital setting warrants incident-to billing is when the physician's office is -confined to a separately identifiable part of the facility and cannot be construed to extend throughout the entire facility,- CMS says. For instance, if a privately practicing oncologist rents a small wing of a large hospital to practice, Medicare will accept incident-to billing for this practice.

And to meet the requirement of representing a -direct financial expense- to the physician, the NPP must be an employee or independent contractor of the supervising physician's practice.

Dodge Trouble by Checking Non-Medicare Rules

-The concept of incident-to is a Medicare rule,- Templeton says. So other payers may or may not follow Medicare guidelines on this issue, she says. You may even have to explain the incident-to concept to your commercial payers.

Try this: For commercial payers, follow these tips from Templeton:

- Read your commercial payer contracts.

- Ask the payer for clarification. 

- Follow Medicare rules when providing services for patients whose insurer you are not contracted with, because there may be variations in how non-Medicare payers reimburse for these services.

- Understand how commercial payers apply guidelines to these services (for example, regarding physician presence within the office suite) in a physician office-based oncology setting, particularly for chemotherapy administration.