Ophthalmology and Optometry Coding Alert

Want 15 percent more reimbursement? Make sure you memorize these rules.

Billing your services incident-to allows you to collect 15 percent more for non-physician practitioners’ visits than you would if the NPPs billed under their own National Provider Identifiers (NPIs) — but that extra money isn’t simply guaranteed to you every time you record a doctor’s NPI on an NPP’s claim. Instead, you need to meet several very specific criteria to bill this way, or you could risk chargebacks.

Check out the following five tips from Danielle Shaw, PA-C, a physician assistant in Durham, NC, that can help you maximize your incident-to payments.

1. Ensure That the Physician Has Seen That Patient Before

Most coders know that incident-to only applies if the physician initiated the patient’s treatment plan, and then the NPP is treating the patient in accordance with that plan. But don’t assume that just because the doctor is involved in the patient’s care, it’s enough to count as incident-to. The doctor needs to initiate the treatment and be involved throughout the entire treatment cycle.

2. Make Sure Changes Are Updated by the Doctor

Don’t keep billing incident-to for a long time after the last physician visit, Shaw says. “If the doctor hasn’t seen the patient in a year and the NPP is still billing incident-to, it could be hard to argue that the NPP is still working off that old treatment plan,” she says. “If you look through the encounter notes, you’ll be able to tell if an NPP has handled visits and treatments that aren’t on the MD’s treatment plan, and if that’s the case, you have to bill under the NPP’s number and not the doctor’s. You’ll collect 15 percent less but at least you’re in accordance with the incident-to rules.”

3. The Physician Must be Available to the NPP

All incident-to services require direct supervision by the physician. This means that the supervising physician must be immediately available within the office suite. Immediately available does not allow by telephone, as the physician’s physical presence is required. Additionally, the NPP must be providing services within his/her scope of practice as determined by state law in which the NPP practices.

4. Adhere to the Treatment Plan

Services provided by the NPP under incident-to must be specific to the treatment plan and follow-up care specified by the physician in a prior visit. There can be no changes to the treatment plan by the NPP (including medication changes) or new problems assessed by the NPP to bill incident-to compliantly. If any changes aremade or new problems are assessed, the visit must be billed under the NPP NPI and is subject to 85 percent reimbursement.

5. Shared Visits Differ from Incident-to

You shouldn’t confuse incident-to billing with the split/shared billing rule for inpatient visits, which allows physicians to perform part of an E/M visit and sign off on the rest of the E/M service as provided by a non-physician. “If you’re not in a hospital, don’t get involved with split/shared visit billing,” Shaw says. “Just focus on the incident-to rules instead.”