Orthopedic Coding Alert

Remember, the end of 2020 might also be the end of incident-to.

Uncertainty swirls about the future of incident-to billing, as the practice is still accepted by Medicare for CY 2020. This could change in 2021, as Medicare mulls the nullification of the entire incident-to practice.

As a coder, you’ll want to be spot-on with your incident-to claims in 2020, since it could mark the last year your practice take advantage of this profitable Medicare policy.

Stay on top of compliance issues by reviewing this incident-to Q&A with Jean Acevedo, LHRM, CPC, CHC, CENTC, president and CEO of Acevedo Consulting Incorporated in Delray Beach, Florida

Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania

Could you provide a brief explanation of what incident-to billing is, and how it benefits billing reimbursement?

Acevedo
Incident to billing, in the simplest of terms, is a Medicare benefit that allows a physician practice to bill for services personally provided by ancillary staff under the name and NPI of the supervising physician or nonphysician practitioner (NPP).  Done correctly, it can add 15% to a practice’s bottom line when services are performed by a nurse practitioner, physician assistant, or clinical nurse specialist – an NPP.

So, an NPP can only bill incident-to a physician if they are following an established plan of care?

Acevedo
Correct.

Falbo
The NPP must following the established plan of care of the physician. If it is an established patient with a new problem, the NPP can still see the patient, but must bill under their NPI [National Provider Identifier] and receive 85 percent of the physician fee schedule amount.

Incident-to guidelines do not allow an NPP to bill incident-to a physician’s services (i.e., under the physician’s PIN) when a new problem is addressed.  This could happen in a situation when the patient was scheduled to be seen for an established problem but brings up a new problem during the course of the visit.  Once a new problem is introduced, the visit would need to be billed under the NPP’s NPI, not the physician’s.

Medicare also says that the NPP must be working under ‘direct supervision’ by a physician in order to bill incident-to — even if they are following an established plan of care?

Acevedo
That is correct. Those services should be billed to Medicare directly under the NPP’s name and provider number [NPI].

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

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

Acevedo
This is an area that often causes confusion, especially since an [NPP] does not need a doctor in the office to be able to treat and care for a patient in most cases. And, Medicare would agree.  Only they would say just bill the services directly under the NPP and accept the 85 percent reimbursement if the physician is not in the office suite.

However, if you want to bill under the supervising physician and be paid at 100 percent of the allowable, a doctor with the practice must be in the office suite. For example, the physician cannot be: across the street, three blocks away, or available via cell phone (but not in person).

The issue of “immediate availability” is one of patient safety; for example, if the patient has an adverse reaction to an injection, or passes out during a routine venipuncture, the physician must be immediately available to provide care to the patient.