Orthopedic Coding Alert

Medicare benefit can maximize your payouts.

Orthopedic practices that provide services incident-to the physician for Medicare patients must constantly be aware of potential roadblocks to a successful claim.

Why? The resultant coding could end up in the payer's denial pile; or, you might be undercoding for your practice's services, which will no doubt impact the bottom line.

Check out this FAQ on the ins and outs of incident-to, and make sure you're coding is on the money every time.

Q: What is incident-to billing, and how does it affect reimbursement?

"This is a huge question that could take pages to explain," says Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh. "But, in a nutshell, incident-to billing is when an advanced practice provider [APP] - like a PA-C or CRNP - sees an established patient in the office for an established problem with an established course of treatment outlined by one of the physicians within the practice."

Further, a direct employment relationship must exist between the APP and the physician. "Both should be employed by the same entity, the physician should employ the APP, or the APP must be formally leased to the practice at the time of the service" in order to bill incident-to, Hauptman explains.

(Note: APP is an acronym that's gaining some steam in the medical community; according to Hauptman, it's starting to take the place of nonphysician practitioner [NPP]. "The APP community does not like the term NPP. Advanced practice provider is their preferred titling for this group of clinicians.)

According to Mary I. Falbo,  MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pennsylvania, an APP/NPP's service qualifies as incident-to only after the following criteria are met:

"The services must be an integral, although incidental, part of the physician's professional service, commonly rendered without charge or included in the physician's bill; and the services must be "of a type that are commonly furnished in physician's offices or clinics."

Payout: When you are able to bill an APP/NPP service incident-to the physician, then the APP/NPP can bill under the physician's national provider identifier (NPI), resulting in 100 percent reimbursement for the service. If the APP/NPP bills with his NPI, the practice will receive 85 percent of the allowable reimbursement for the service.

Q: Does an APP/NPP have to be following an established plan of care to bill incident-to?

A: "This is correct," Hauptman confirms. "Once the patient speaks of a new problem, incident-to would not be the appropriate route of billing. If the patient or the problem is new, the APP would bill directly under his/her own NPI number."

Q: Who qualifies as an APP/NPP, for incident-to billing purposes?

A: "Medicare has a list of APPs that includes, physician assistants [PAs], nurse practitioners [NPs], nurse specialists, clinical social workers, speech language pathologists, etc.," explains Hauptman.

For a full list of qualifying providers, refer to the Medicare 855i application at: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855i.pdf.

Q: What does Medicare mean when it says the NPP must be working under 'direct supervision' of a physician to bill incident-to?

"Direct supervision in the office setting means that the physician is in the office suite," says Falbo. "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."

Q: If there is no 'direct supervision' by a physician, the NPP cannot bill incident-to?

"True," says Falbo. "If you have more than one physician in your practice and neither is in the office suite when the services are rendered, you would also be correct that the claim would need to be billed under the NPP's NPI, if the NPP is credentialed by the payer."

Of note: "Keep in mind that incident-to guidelines weredeveloped by Medicare, and other insurance carriers do not necessarily follow Medicare's lead," explains Falbo. "It is important to check with the third-party payers to ascertain if they follow Medicare's incident-to guidelines ... or obtain clear guidelines as totheir requirements."

Q: Are incident-to services for E/M services only? Can you ever report a procedure incident-to?

A: Incident-to billing is only for evaluation and management (E/M) services, says Hauptman. You can't report procedures using incident to rules; you have to bill those services under the APP/NPP's NPI, Hauptman continues.