Oncology & Hematology Coding Alert

Question: We use a hospital-based nurse practitioner (NP). She operates under the direct supervision of the office medical oncologist, so we bill under the physician's number. However, the NP is registered with the state and has her own provider number for Medicare and Medicaid. Which provider number should we use?
           
Utah Subscriber

 
Answer: "Incident to" services are a Medicare convention that applies only in the office, not in an outpatient hospital setting or in a hospital-owned clinic. 
 
The NP can only perform these services on established patients with a prescribed plan of treatment for an existing condition. If it is a new patient, or if the patient presents with a new problem, the visit must be billed under the NP's number, whether the physician is present or not. Not all payers recognize incident to in the same manner, so check with non-Medicare payers for their guidelines.
 
For Medicare visits billed by the physician or NP, bill appropriate NP services as incident to the physician's service and under the physician's provider number because it provides higher and fair reimbursement
 
Many practices erroneously believe that if a midlevel provider has a UPIN and provides chemotherapy follow-up visits, for example, or other services integral to a physician's personal professional services, they are obligated to submit the claim using the midlevel provider's UPIN. This type of billing pays 15 percent less than what the physician would be paid.
 
Rather than submitting the claim under the midlevel provider's UPIN, you may be reimbursed at 100 percent  if the claim is submitted as incident to physician services for Medicare patients.
 
Practices must ensure that three key characteristics are met before doing so:
 
1. A physician who is a member of the oncology practice but not necessarily the patient's own physician must be present in the office at the time the midlevel provider administers the chemotherapy
 
2. The NP is employed or contracted by the oncology practice
 
3. The procedure is included in the state's scope of practice for the NP.