Oncology & Hematology Coding Alert

Identify NPP services, describe direct supervision, and check payer guidelines.

‘Incident to’ billing is nearly routine in oncology practices. E/M follow up visits are often performed by NPPs in oncology practices and billed incident-to under the physician, experts say. Billing a service ‘incident-to’ requires you to follow stringent rules. However, not all services will qualify. You lose money every time you miss a service which qualifies as an ‘incident to’ service and you will invite trouble every time one is billed but does not qualify. Check out this expert advice before filing the next ‘incident to’ claim.

For a service to qualify as ‘incident to’, the following four key rules apply:

• The individuals performing the ‘incident to’ service must be directly employed or leased by the physician practice/group/entity
• The services can only be performed in an “office” setting (POS 11), a patient’s home (POS 12) or institutions other than a hospital or skilled nursing facility
• Services are limited by the state scope of practice
• “Direct supervision” must be provided by a physician in the same group practice at and during the time of service.

Earn When NPPs Provide ‘Incidental’ Services

What is ‘incident to’ billing? Medicare has introduced ‘incident to’ billing to allow physician practices to bill for services personally provided by ancillary staff. The staff provides services under the name and national provider identifier (NPI) of the supervising physician or non-physician practitioner (NPP).

Who are NPPs?  NPPs are also known as mid-level providers (MLPs) or advanced practice providers (APPs). They are usually physician assistants (PAs), nurse practitioners (NPs) or certified nursing specialists (CNSs), although the CMS definition of NPP also includes social workers, therapists, and others. When any qualified NPP performs a service, the physician practice can earn the full amount if the service performed qualifies to be paid ‘incident to’ the billing provider.

For a complete list of providers considered NPPs, check out: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r1764b3.pdf.

Amplify revenue: If the visit meets the ‘incident to’ provisions, the NPP can bill under the supervising physician’s NPI, which will result in 100 percent of the physician fee schedule payment allowed amount. If the same visit is billed with the NPP’s NPI, you’ll only receive 85 percent reimbursement for the same service.

Check Payer Guidelines before ‘Incident to’

You are wrong to assume all payers will accept ‘incident to’ claims. ‘Incident to’ billing is an exclusive concept of Medicare, and payers which follow Medicare payment guidelines. Some payers may require the NPP’s services always be reported under the NPP’s name and NPI, experts warn. It’s important to regularly check with payers to understand how require the coding and claim submission for these types of services.

No Plan of Care, No ‘incident-to’

Before you bill any ‘incident to’ service, confirm you have a defined plan of care. According to Medicare’s criteria, an NPP can only bill ‘incident to’ a physician if he / she is following an established plan of care for an established problem known to the practice. New patient visits, as well as services for new problems do not meet Medicare’s ‘incident to’ criteria. A physician must personally perform an initial service and establish a plan of care for the particular condition. The physician must also remain actively involved in the patient’s course of treatment.

“New patient visits do not typically qualify as ‘incident to’ services. For the plan of care to be established, the treating physician will have seen the patient face-to-face and provided a documented assessment and plan of care for the patient’s condition presenting to the NPP,” says Kelly Loya, CPC-I, CHC, CPhT, CRMA, Associate Partner at Pinnacle Enterprise Risk Consulting Services LLC located in Charlotte, North Carolina. “Also do not make the mistake of thinking if the patient is established the visit would qualify.”

While some services would be appropriate, not all services provided to established patients qualify as an ‘incident-to’ service. Sometimes an established patient will present to the NPP for their regularly scheduled follow up visit for their existing diagnosis however, during the course of the visit a new complaint or problem is found and evaluated. The new complaint may come from the patient, it may be discovered by the NPP during the exam, or result from diagnostic test findings. When this is the case, the visit no longer meets ‘incident-to’ guidelines because the new complaint has not been assessed by a physician and a plan of care established, therefore it must be billed directly under the NPP performing the services.

The terminology is clear: ‘Incident to’ means the services of the NPP are incidental to the physician’s services and established treatment plan.

Check these examples: The NPP may do a medication check for a patient with an established plan of care for chemotherapy. These services are incidental to the physician’s treatment.

Or the NPP may see a new patient with a new complaint of severe fatigue and nausea. This does not qualify for ‘incident to’ as the physician hasn’t seen the patient and there isn’t any plan of care. You would code for these services directly under the NPPs NPI.

Direct Supervision is Mandatory for ‘Incident to’

Medicare stipulates an NPP must be working under “direct supervision” of a physician to bill ‘incident to’. If you cannot meet these supervision rules, don’t pursue ‘incident to’ billing of the claim.

What is direct supervision? In order to meet Medicare’s direct supervision guidelines, the supervising physician:

• Must be physically present in the office suite
• Need not be physically present in the treatment room
• Must be readily available to provide assistance and direction to the NPP
• Need not actually see the patient

“Yes, this means for the duration of the service if the supervising practitioner does not satisfy all requirements, the supervision component has not been met and should be billed with the NPP’s NPI. Expected reimbursement is 85 percent,” Loya says.

Why direct supervision? This is in interest of patient safety. If the patient has an adverse reaction to a chemotherapeutic medication, the physician must be immediately available to provide care to the patient.

No physician in office suite: The supervising physician cannot be across the street, three blocks away or available via cell phone. If there is no physician physically present in the office suite during the time of the NPP service, the service must be billed to Medicare under the NPP’s name and NPI.

Documentation is key: As a best practice, the NPP should describe in the documentation the supervising physician was in the suite at the time of the service. This will allow for a clear illustration the supervision requirement has been met. “In the event this is not stated clearly, supervision must be supported in some other manner and consistently verifies the presence of the qualified physician to provide the necessary supervision,” Loya says.

State laws may differ: State laws sometimes lack clarity in supervision guidelines. However, Medicare directly states Medicare’s federal ‘incident to’ rules supersede any state’s rules — and the feds’ rules are often more restrictive, experts say.

Some state boards may only require general supervision, or the physician be available by phone, in order to consider an NPP “directly” supervised. Don’t confuse this clinical practice guideline with the reimbursement guideline for services billed under the ‘incident to’ provision.

Any Physician Can Provide ‘Incident to’ Supervision

Medicare allows practices to bill ‘incident to’ the physician as long as the NPP has direct supervision of one qualified supervising physician within the practice while the NPP is performing the service. The qualification of the provider to supervise is a critically important requirement especially for highly specialized services such as radiation oncology. The physician who established the plan of care doesn’t necessarily have to be the one supervising.

Chapter 26 of the CMS Claims Processing Manual addresses which physician to bill under when the patient’s treating physician is not in the office but another physician with the group provides direct supervision.

Example:  An NPP is treating a patient and Dr. X is the supervising physician. However, the NPP is following Dr. Y’s treatment plan, and Dr. Y is not present during the treatment. In this example, you would report the service under Dr. X’s NPI as he / she was the one who was physically present in the office suite during the NPP service.

Report Dr. X’s NPI in item 24J of the 1500 claim form (or its electronic equivalent) as well as the physician’s name in item 31.

Then, you list the physician who formed the plan of care (Dr. Y) in item 17 of the 1500 claim form (or its electronic equivalent).