Advanced Search

Oncology & Hematology Coding Alert

Increase Pay by 18 Percent:

Maximize Incident-To

Published on Sun Jun 01, 2003

Just a change in identification and the right documentation and payers will see a higher-paid physician's service when you report nonphysician practitioner (NPP) claims as incident-to.

Incident-to is a Medicare reimbursement policy that, under certain circumstances, allows you to report services rendered by NPPs under the supervising physician's number, says Kenneth Lambert, CPC, CCS-P, CPC-H, CCS-P, director of coding/quality services at MMR Management Team in Jacksonville, Fla.

The result: You receive reimbursement for those services at 100 percent of Medicare's allowable fee schedule instead of 85 percent of the free schedule allowed under the NPP's number, says Judith Richardson, RN, MSA, CCS-P, a senior consultant with Hill & Associates.

Your incident-to service should reflect this 18 percent increase meaning your NPP should perform a service as if the physician did it, she says. The service must be medically necessary and an "integral, though incidental" part of the physician's professional service. Your practice should commonly render it without charge or include it in the physician's bill, Richardson says.

In addition, the service under incident-to must qualify as one of those your NPP, under state law, can perform. Review your state's licensure and scope-of-practice rules concerning what physician assistants (PAs) and nurse practitioners (NPs) can perform, says Dennis Grindle, CPA, a partner in healthcare consulting at Seim, Johnson, Sestak & Quist LLP in Omaha, Neb. Use these statutes and regulations as your "baseline" for determining incident-to, he says. There's no sense in wasting your time or committing fraud reporting incident-to services your NPP shouldn't be performing anyway.

Note that you can also bill for any supplies your NPP may use while performing an incident-to service, he says.

When You Should Use Incident-To, 99211

Incident-to is a useful payment method for oncology practices, but 99211 can poison your reimbursement on incident-to claims if you're not careful.

NPs, for example, have the qualifications to render many of the services frequently used in patient care, such as nurse assessments, reported as a level-one established patient E/M visit, 99211 (Office or other outpatient visit), and chemotherapy administration for example, 96410 (Chemotherapy administration, intravenous; infusion technique, up to one hour), J9000 (Doxorubicin HCl, 10 mg), J2405 (Injection, ondansetron HCl, per 1 mg) and 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) if the NPP administered the therapy sequentially to chemotherapy.

You may encounter resistance from carriers when reporting 99211 with chemotherapy administration codes.

In fact, whether to report 99211 incident-to "is the biggest incident-to issue in the oncology office," says Lynn Anderanin, CPC, senior coding consultant at Healthcare Information Services LLC in the Chicago area. Some payers and practices do not report 99211 for patients who are in the office only to receive chemotherapy administration. They see it as a routine nurse assessment that doesn't seem to warrant a separate payment, especially under incident-to.

Although you shouldn't automatically report 99211 every time a patient comes into the office, you could report 99211 incident-to if your documentation supports doing so, Anderanin says.

The best way to decide whether to report 99211 incident-to is to refer to or create an office policy that stipulates if and when you should report it, Anderanin says. Your policy should specify what constitutes a 99211 service and what documentation is necessary to warrant reporting it, she says. "This should be a policy used consistently by everyone in the office," she says.

If you decide to report 99211 as incident-to, documentation from Medicare should help your case. Section 15400 D of Medicare Transmittal 1776, released Oct. 25, 2002, states, "On days when a patient receives chemotherapy administration but the physician has no face-to-face contact with the patient, the physician may report and be paid for incident-to services furnished by one of the physician's employees, in addition to the chemotherapy administration "

To read more on this controversy, refer to "Conflict of Opinion: 99211 and Chemo Administration: Separate Services?" in the May 2002 Oncology Coding Alert.

Don't Create Denial Incidents:Follow the Rules

When you report services rendered by NPPs as incident-to, you should follow these guidelines:

  • The setting must be an office or clinic location, in a patient's home, or in an institutional office setting to report incident-to, Grindle says. An example of an institutional office setting would be the section of the nursing home an oncologist rents out to provide services. You can report under incident-to those rendered in the leased area, he says.
  • The patient must be an established patient with no new problems, Richardson says. You cannot report incident-to for new patients, established patients with new problems, or consultations, she says.

    In other words, do not report incident-to services if a physician hasn't seen the patient first and initiated treatment for the presenting problem, Grindle says.

    You need to pay attention to this requirement, Richardson says. If you have a busy practice and on any given day patients are going in and out, your PA may see several successive patients. If the PA bills incident-to for all relevant services, chances are an error will occur. For example, a new patient comes into the office, and the PA forgets to "change hats" and report under his or her personal identification number (PIN), she says. If your practice is this busy, and you fear PAs may routinely make this mistake, consider skipping incident-to billing altogether, she says, to save time.

  • Your NPP must provide the services under the direct supervision of the physician under whose PIN you report. This requirement further demands the following:

    1. The supervising physician must be in the office suite, but doesn't have to be in the room where the NPP renders the service, Richardson says.

    That freedom to leave the room, however, doesn't allow physicians belonging to your clinic to provide supervision while in the hospital, despite availability by phone. Your supervising physician must be "within the four walls of the clinic" to immediately provide care or change treatment plans if needed, Grindle says.

    If the physician must leave for an emergency and your PA does a follow-up visit with a patient, you cannot report that incident-to either, Richardson says.

    2. The supervising physician does not have to be the same one who initially saw the patient, Richardson says, as long as the physicians belong to the same practice, that is, are members of the same group. In fact, the supervising physician doesn't even have to belong to the same specialty as the initial physician, she says, as long as they belong to the same multispecialty practice.

    3. The supervising physician must perform the initial service and on-going services at a frequency that shows the doctor's continued active involvement in the patient's care, Richardson says. That's because the NPP is providing services that are integral to the physician's services, not a replacement for them. The number of times the physician must provide face-to-face services with the patient varies, she says. Some practices determine every third or every fifth visit for involvement, she says.

  • Your NPP's documentation must meet the same requirements as the physician's for the specific service, Richardson says.

    The documentation must support the code or level of service, she says. Your documentation should also include a simple statement explaining that the NPP performed the service under the physician's supervision and name the doctor.

    The supervising physician does not have to include a written note, or even a cosignature, unless your state requires it, Richardson says. Supervising physicians must append notes to services performed by residents, but not NPP's billing incident-to, she says.

     

    • Other Articles in this issue of

    Oncology & Hematology Coding Alert

    View All