Oncology & Hematology Coding Alert

Your practice may be losing 15 percent reimbursement if you ignore the basics.

Non-physician practitioners (NPPs) are an integral part of oncology services. Billing NPP services can cost your practice if you aren’t aware of the ‘incident-to’ rules. “Remember, ‘incident-to’ is traditionally a Medicare professional fee concept however it is also important to check whether other payers recognize and reimburse using the concept, understand if the rules are the same or different and whether there is a difference in reimbursement,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Director of Reimbursement and Advisory Services, Altegra Health, Inc.

Reason: There’s money on the line. Under certain circumstances, the NPP can bill ‘incident-to’ under the physician’s National Provider Identifier (NPI), which will net your practice 100 percent reimbursement under the physician fee schedule (PFS) from Medicare. If you bill under the NPP’s NPI, reimbursement is reduced to 85 percent of the PFS for the same service.

Follow this incident-to advice to ensure you know when you can — and can’t — capture the full 100 percent.

Ensure Established Plan Before Choosing Incident-To

If you are billing ‘incident-to’ the physician, the NPP must be following an established plan of care that the physician has already formulated.

In short: When billing ‘incident-to’ the physician, NPPs cannot see new patients, or established patients with new problems.

“[Incident-to] services must be part of the physician’s services to diagnose or treat the injury or illness, and be provided under the physician’s direct supervision,” according to Jean Acevedo, LHRM, CPC, CHC, CENTC, president and senior consultant with Acevedo Consulting Incorporated in Delray Beach, Fla.

Additionally, ‘incident-to’ services are services or supplies an NPP performs as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness, according to Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of Denver’s MJH Consulting. “The NPP performing incident-to services must be an expense to the physician practice … an employee, independent contractor, leased employee,” she adds.

Caveat: Medicare only covers ‘incident-to’ services in the office or home places of service, Hammer warns. Services your NPPs perform in a facility do not fall under ‘incident-to’. Further, not all payers embrace the incident-to policy. “Some payers may require that NPP’s services always be reported under the NPP’s name and NPI even if they meet the Medicare incident-to requirements,” Hammer says.

Meet Direct Supervision Rules

In order to bill ‘incident-to’ the physician, the NPP must be working under the “direct supervision” of a physician in the practice, which means that the physician must be in the office suite and immediately available to render services to the patient during the entire time of the visit or services rendered.

This is an area that often causes confusion, especially since, based on scope of practice, an NPP wouldn’t need supervision to provide the services typically rendered to most patients. However, if you want to bill Medicare ‘incident-to’ the physician “and be paid at 100 percent of the allowable, a doctor with the practice must be in the office suite,” explains Acevedo.

What it means: For example, the physician cannot be across the street, three blocks away, or available via cell phone but not in person, she says.

The direct supervision rule is one of patient safety. If anything goes wrong during the ‘incident-to’ service, a physician must be on site to remedy the situation. “For example, if the patient has an adverse reaction to an injection or passes out during a routine venipuncture, the physician must be immediately available to provide care to the patient,” says Acevedo.

And “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,” Hammer says.

Do the Math

As noted above, if the encounter you are billing meets the incident-to requirements, you can report the NPP’s services under the physician’s NPI and expect 100 percent reimbursement.

Payoff: According to the Medicare physician fee schedule, 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity…) carries 3.03 non-facility relative value units (RVUs). That means when you bill the service under your physician’s NPI and receive 100 percent reimbursement, you can expect to receive about $108 (3.03 national, unadjusted, nonfacility RVUs times the current 35.7547 conversion factor).

If, however, you report this claim under the NPP’s NPI, and you could have billed incident-to, you’ll only collect about $92, or 85 percent, for the same service.