Orthopedic Coding Alert

If your orthopedic practice isn’t reporting services incident-to the physician when it can, it’s leaving literal money on the metaphorical table.

Why? This billing practice allows nonphysician practitioners (NPPs) to provide evaluation and management (E/M) services to patients without the physician’s accompaniment. Correctly reporting incident-to means that you can bill your NPP’s services under the National Provider Identifier (NPI) of the physician; this will garner you 100 percent of the E/M payment, as opposed to the 85 percent reimbursement rate that accompanies the NPP’s NPI.

The catch: There are some very specific rules for reporting incident-to, and failure to follow even one of them will raise the eyebrows of auditors on the lookout for upcoders. Check out our advice on reporting incident-to correctly every time.

Medicare Created Incident-to

First things first: You need to know how to proceed with potential incident-to claims — because not all payers will recognize the coding convention, says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare in Lansdale, Pennsylvania.

“It is important to check with each of your carriers before billing services incident-to,” she warns. “Keep in mind that incident-to guidelines were developed by Medicare, and other insurance carriers do not necessarily follow Medicare’s lead. It is important to check with the third-party payers to ascertain if they follow Medicare’s incident to guidelines or state law or obtain clear guidelines as to their requirements.”

The Centers for Medicare & Medicaid Services (CMS) defines incident-to services as “services or supplies furnished 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.”

CMS reports that in order to be covered as incident-to the physician, the service must:

• “Be an integral, although incidental, part of the physician’s professional service;
• “Of a type that are commonly furnished in physician’s offices or clinics; and
• “Furnished by the physician or by auxiliary personnel under the physician’s direct supervision.”

If your encounter doesn’t meet all these criteria, don’t even think about coding incident-to.

Incident-to Strictly for Outpatient E/Ms

Remember that E/M codes are what incident-to guidelines were designed for. There’s no incident-to billing of a procedure code.

Also, as CMS insists that incident-to services must be “commonly furnished in physician’s offices,” you won’t be able to report hospital E/M codes.

Lastly, the patient must be established in order to report a service incident-to.

Takeaway: You’ll be reporting your incident-to claims with office/outpatient codes 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.).

Find Plan of Care

An NPP can only bill incident-to a physician if they are following an established plan of care, Falbo confirms. And CMS seems to be cracking down on this criteria, according to recent guidance from the CMS Medical Review (MR) Department.

From February 2022 CMS MR Department guidance:

“An initial history and physical performed by a non-physician practitioner, although the physician is documented as being present or in the office suite and immediately available, is not covered under the ‘incident to’ guidelines. The physician must perform the initial service. This includes the history and physical, examination portion of the service, and the treatment plan. It is expected that the physician will perform the initial visit on each new patient to establish the physician-patient relationship.

“Our MR will deny or down code claims for initial office visits billed as ‘incident to’ when a non-physician practitioner performs the initial history and physical,” CMS cautions.

Know all Direct Supervision Rules

Incident-to services must be performed under the direct supervision of the physician. CMS states that “Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.”

The physician that is performing the direct supervision doesn’t have to be the same physician that established the plan of care. If there is no direct supervision of any kind, however, you cannot code incident-to; revert to coding the service under the NPP’s NPI.

CMS further indicates that “this does not mean, however, that to be considered ‘incident to,’ each occasion of service by auxiliary personnel (or the furnishing of a supply) need also always be the occasion of the actual rendition of a personal professional service by the physician. Such a service or supply could be considered to be “incident to” when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflects his/her active participation in and management of the course of treatment.”