Oncology & Hematology Coding Alert

Answer: In order for a physician practice to bill E/M services performed by a mid-level provider as incident to a physicians professional services, it must meet specific criteria that ensure the physician is actively involved in patient care. If these criteria cannot be met, the E/M service should be billed as a physician assistant or nurse practitioner visit.

In the course of chemotherapy treatment it is not uncommon for a mid-level provider to administer the drug. Prior to the actual administration of the drug, the mid-level provider asks questions and checks vital signs to gauge the status of the patient. He or she will in turn relay the findings to the physician managing the patients treatment.

But it is the presence of the following four factors that will determine how it should be billed:

1. The service is commonly rendered without
charge or is included in the physicians bill;
2. The service performed is commonly furnished
in the physicians office;
3. There is direct, personal supervision by the
physician; and
4. The mid-level provider is an employee of the
supervising physician. Employment
arrangement can include full-time, part-time or
leased employee.

All of the above factors must be met in order for the practice to bill the E/M services as incident to professional services.

In addition, the practice must be able to show that the service provided was an integral part of the physicians personal professional service, despite the fact that the physician did not perform it.

And not all incident to services have to occur when a physician has performed a personal professional service. E/M services can be considered incident to physician professional services during the course of service as long as the physician has performed the initial service, such as coming up with a treatment plan, and subsequent services reflect active participation in managing the course of treatment.

Editors note: This question was answered by Laurie Lamar, RRA, CCS, CTR, CCS-P, reimbursement specialist with the American Society of Clinical Oncology in Alexandria, Va. She also is a member of Oncology Coding Alerts editorial board.