Otolaryngology Coding Alert

Physician's authorization of NPP's services is a rule you can't miss.

The Centers for Medicare and Medicaid Services (CMS) recognizes non-physician practitioners (NPPs) for payment purposes by reimbursing physicians for services provided "incident to" a physician's care. However, CMS has made it clear in 2008's Transmittal 87 that payers will not reimburse these services unless there is physician documentation authorizing the incident-to service.

You could end up dazed and confused if you don't fully understand incident-to rules. But you can't afford not to -- Medicare reimburses at 100 percent of the physician fee schedule when services are billed in the physician's name as an incident-to service, and 85 percent when billed under the NPP's name if incident-to guidelines are not fulfilled.

Fortunately, you have ways to increase your knowledge about incident-to services. Here are 3 important guidelines.

1. Meet CMS-Set Criteria

CMS' Benefit Policy Manual defines "incident to" as "services furnished as an integral although incidental part of a physician's personal professional service." CMS pays NPP office service reported under a physician's NPI at 100 percent, provided you meet these requirements:

• The NPP performs the service in a physician's office (Place of Service 11).
• The NPP performs the service within the scope of her practice and in accordance with state law.
• The physician should establish the care plan for the new patient to the practice or any established patient with a new medical condition. NPPs may implement the established plan of care.
• The physician must be on site when the NPP is rendering the service

A Must: The physician should continue to see the patient at a frequency reflective to the ongoing management of the patient's plan of care as defined by state law. "CMS has no set time period for how long in between episodes the physician must retreat the patient for the carrier to still consider the physician's role as active," says Hugh Aaron, MHA, JD, CPC, CPC-H, Medicare coding and billing expert.

2. Document Supervision

Since 2008, CMS has pushed for the physician to document his approval of an NPP to provide follow-up services.

Example: Your otolaryngologist diagnoses a new patient with acute sinusitis (461.9), and billed the service with 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the presenting problem[s] are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family). His plan of care includes follow-up services to assess the patient's medication compliance and response. These services may be provided by the physician or practice's nurse practitioner (NP).

The initial physician service in this case is reported as 99203 under the physician's NPI, which pays about $103 in reimbursement based on the Medicare fee schedule non geographically adjusted (3.03 RVUs multiplied by 2011 conversion factor of 33.9764). Additionally, follow-up services provided by the NPP which might be reported (e.g., 99213) under the physician's NPI, after being provided, as "incidentto" the physician's plan of care.

The NPP should provide evidence of the required physician supervision. This can easily be accomplished through a simple notation in the record, such as "Service performed under thesupervision of Dr. Smith." A co-signature is not required for billing purposes, but may be required for licensure issues involving physician assistants or as required by the state.

3. Be Aware of NPP Limitations

When a patient comes to the office when no physician is around, the NPP can see and treat her. The NPP can even provide a service within his or her state law guidelines for scope of practice as long as the state's supervision requirements are met. However, in this case, you should bill the services out to Medicare under the NPP's own NPI and not the physician's, NPI. Medicare will pay for the service at 85 percent of the fee schedule.

Advice: For non Medicare payers, get in writing what their NPP policies are. It's important you ask these questions: (1) Do they allow incident to billing? (2) Do they follow Medicare guidelines? (3) Do they credential NPP's with their own provider number for that payer for you to bill out the NPP individually?

It's essential that you know these information for each of your payers. You shouldn't assume that every payer follows Medicare's rules. This includes your state Medicaid program.  Many state Medicaid programs have their own individual NPP billing and credentialing rules separate from Medicare and do not necessarily accept incident to billing.

Option: By definition, a practice cannot bill a new patient visit or for a new condition performed by a physician assistant (PA) or NP under the supervising physician's NPI number as incident to. Instead, you must submit the claim with the PA's or NP's NPI. Similarly, by definition, a practice cannot bill any patient visit performed by a physician assistant (PA) or nurse practitioner (NP) under a physician's NPI number as incident to. Instead, you must submit the claims with the NPP's NPI.