Oncology & Hematology Coding Alert

Most oncology practices can bill many more nonphysician practitioner services than they think, so now's the time to brush up on the incident-to how-to's. Practices can bill NPP services as either incident-to a physician or under the NPP's own provider number, so practices need to decide which method works best for them. Too many practices reduce this to a simple economic equation. They see that incident-to services are reimbursed at 100 percent of the Physician Fee Schedule and that NPP services get 85 percent. But there's more to it than simple math, experts warn.

Coders and NPPs need to make sure they follow the rules when billing for services incident-to the physician.

"The biggest problem with incident-to billing is that people aren't aware of the documentation requirement for the supervision component," says Carol Pohlig, BSN, RN, CPC, reimbursement analyst for the University of Pennsylvania.

To bill a service incident-to, you need physician supervision from somewhere in the office space. To document this, Pohlig explains, you need at least a simple phrase in the progress notes such as "performed under the supervision of Dr. X," or "service provided under supervision of Dr. X." It's a relatively simple thing to do, but "a lot of people fail to do that," Pohlig says.

New patients and, more important, established patients with new problems add another monkey wrench to the incident-to machine. To bill NPP services incident-to a physician, you must provide the services to an established patient with an established plan of care. If an NPP sees a patient for any other reason, the service must be billed under the NPP's provider number.

Busy practices make critical mistakes in this area, especially when they're swamped with patients, said Emily Hill, PA-C, president of Hill & Associates in Wilmington, N.C., at a recent Coding Institute teleconference. The NPP will see patient after patient and bill incident-to the physician since these are patients who have been seen by the doctor at some point either today or in the past for the same problem that they're in for today.

That's fine, Hill said. But practices run into trouble when the NPP sees a new patient, or a patient who is presenting with a new problem for which he has not seen a physician. When this happens, the NPP can treat the patient but must bill under his own provider number. The NPP cannot bill incident-to the physician for new patients or for old patients with new problems.

The NPP or the practice biller must make clear when he is seeing a patient incident-to the physician and when he is seeing a patient under his own provider number.

"It can be a tricky and dicey issue to move back and forth" between billing incident-to and billing under the NPP's own number, Hill said. For this reason, she's in favor of NPPs billing under their own number all the time instead of billing incident-to.

Some insurers still do not pay for services billed under NPP numbers, Pohlig cautions. Medicare pays for such services, but not all private insurers have followed the government's lead. Some insurers claim that they pay for these services but are slow about handing out personal identification numbers to NPPs meaning your NPPs can technically bill the insurer, but until they get a PIN from it, they can't bill in actuality.

But when you're dealing with payers that do reimburse for services billed under NPP numbers, Pohlig recommends billing that way rather than incident-to. "It's very restrictive to bill incident-to," she says, so billing under NPP numbers "eliminates a lot of the restrictions."

If you decide to use incident-to billing, it's not all trial and tribulation. While many providers assume that NPP discounts apply across the board, with proper documentation you can bill for the chemotherapy drugs at 100 percent, says Linda Gregory, business office manager for Oregon Hematology Oncology Associates P.C. in Portland. "The 15 percent discount is taken on the E&M and procedure codes (CPT codes). The drug reimbursement (HCPCS codes) are not discounted," she says.