Optometry Coding & Billing Alert

Question: An optometrist in my office wants to bill services under another physician's tax ID within the practice, but I've been taught not to. What should I do?

Oregon Subscriber

Answer: This may be rule number one for all billers: When a physician provides services, only bill the services to the physician who performed the work. The name and national provider identifier (NPI) on the CMS-1500 form must be the name and number of the provider who actually performed the service.

What about "incident-to" billing? One physician cannot provide services incident to another physician.  Incident-to" billing only applies to nonphysician practitioners (NPPs), and even then you must follow a number of guidelines to the letter. In addition, "incident-to" does not apply in hospitals, skilled nursing facilities, or homes.

The rules are clear: You need only read the back of the CMS-1500 form to find the correct guidance in writing: "Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties."

This also applies to third-party billers. The Office of Inspector General (OIG) guidance says, "If the billing company finds evidence of misconduct on the part of the provider that they service, the billing company should  refrain from the submission of questionable claims and notify the provider in writing within (30) days of such determination."

Bottom line: There's too much at stake to risk accusations of fraud. If any physician requests you bill to another doc's NPI, quickly decline, and gently remind him of the consequences.