Oncology & Hematology Coding Alert

Oncology practices that have their physician assistants and nurse practitioners bill Medicare for chemotherapy administration under their unique provider identification number (UPIN) can boost reimbursement by 15 percent if they code chemotherapy administration as a service incident-to physician services.

Medicare guidelines state that a non-physician practitioner such as a physician assistant or nurse practitioner may be licensed under state law to perform a specific medical procedure without physician supervision, and have the service separately covered and paid for by Medicare as a physician assistants or nurse practitioners service. To have the same service covered as incident-to the services of a physician, it must be performed under direct supervision of the physician as an integral part of the physicians personal, in-office service.

According to Medicare guidelines, a physician must be present in the office and immediately available to provide assistance and direction while clinical staff is performing services, says Laurie Lamar, RHIA, CCS, CTR, CCS-P, reimbursement specialist with the American Society of Clinical Oncology in Alexandria, Va.. On the other hand, direct supervision does not mean the physician must be in the same room with the nurse or other clinical staff providing incident-to services.

Also, according to the Medicare guidelines, incident-to physicians services means that the services or supplies are furnished as an integral, although incidental, part of the physicians personal professional services in the course of diagnosis or treatment of an injury or illness.

If the key characteristics of an incident-to service are met (see Incident-to Key Characteristics below), rather than submitting the claim under the mid-level providers UPIN, practices can garner full reimbursement if the claim is submitted as incident-to physician services, says Lamar. Practices do have a choice. If the physician is in-house, its better to bill incident-to.

For oncology practices, chemotherapy administration (96400-96549) represents the most common incident-to service, says Lamar. Most, if not all, states allow nurses and mid-level providers to administer chemotherapy drugs. In fact, many services provided by therapists, technicians and aides could be billed as incident-to physician services. These services commonly should be furnished in the physicians office, and coverage of supplies, such as drugs, must represent an expense to the physician.

Aside from billing for chemotherapy administration, billing incident-to for nurses or other non-physician personnel is commonly coded with 99211 (evaluation and management, [E/M] established patient office or other outpatient visits), says Laurie A. Castillo, MA, CPC, president of Physician Coding & Compliance Consulting in Manassas, Va. Code 99211, the lowest level of E/M service for an office visit involving an established patient, is used because it does not require the presence of a physician and requires minimal supervisory time. It also does not require a physician to perform the three key components history, exam and medical decision-making required in the four higher levels of E/M service.

Many practices mistakenly believe that if a mid-level provider holds a UPIN and provides chemotherapy administration or other services that could otherwise be considered integral to a physicians personal professional services, they are obligated to submit the claim using the mid-level providers UPIN, which carries a 15 percent discount to what physicians would be paid. Direct physician supervision is the key element that will allow a practice to bill services provided by a physician assistant or nurse practitioner as incident-to, rather than using the mid-level providers UPIN to bill for the service separately.

Medicare guidelines make it clear that a physician does not have to perform professional services in conjunction with incident-to services. Rather, incident-to services can be performed without professional services occurring at the same time as long as the services are part of the course of treatment and reflect the physicians active participation in the management and care of the patient. There must be direct, personal, professional services furnished by the physician to initiate the course of treatment that the service being performed by the non-physician practitioner is an incidental part of. Moreover, there should be subsequent services performed by the physician to show active participation in the care and treatment of the patient.