Otolaryngology Coding Alert

Otolaryngologists can free up a lot of their time to perform well-paid procedures if they allow their non-physician practitioners (NPPs) more access to their patients. But to do so correctly, they need to understand the Healthcare Financing Administrations (HCFA) incident to guidelines to distinguish when their NPPs can bill incident to, and when they should bill under their own names and provider identification numbers.

When physicians use their mid-level providers and bill incident to, it is as though they are saying they performed the procedure themselves. Accordingly, under Medicares incident to guidelines, physician assistants, nurse practitioners and other NPPs, such as nurses and certified medical assistants, as well as limited license providers, such as audiologists, are allowed to bill under the supervising physicians name at 100 percent of the fee schedule.

Three Conditions for Incident to

The Medicare guidelines stipulate that a physician may bill incident to for services provided by his or her employees under the following three conditions:

1. The NPP either is an employee or a leased employee.

2. The plan-of-care must be initiated by the physician
and supervision by the physician must be ongoing.

3. A physician has to be on site in the office suite when
the service is provided.

Note: In rural areas, the guidelines have been relaxed to increase access to providers.

Incident to Restrictions

Otolaryngologists employ any number of different non-physician practitioners, including audiologists for hearing tests; nurse practitioners (NPs) and physician assistants (PAs) to perform straightforward post-operative followup and provide care for uncomplicated cases, such as simple otitis media; nurse allergists, who perform allergy tests and administer shots; and speech pathologists.

Unfortunately, many otolaryngology practices are unfamiliar with the guidelines for incident to usage, says Randa Blackwell, a coding and reimbursement specialist with the department of otolaryngology at the University of Maryland in Baltimore. In many cases, she notes, if a patient comes in and sees a technician or an audiologist without the service being medically directed by a physician, then the service shouldnt be billed incident to.

Incident to should not be billed when the audiologist is in the physician suite and the otolaryngologist is in the hospital suite, but it happens, Blackwell says. It also should not be billed when a technician performs a provider service that he or she is not qualified to perform without supervision. In those instances, the physician must be present.

She notes that audiologists, as mid-level providers, are capable of providing unsupervised services such as audiograms using their own personal identification numbers (PINs). But if a nurse or an office technician provides the services instead, the physician may need to directly participate in the care of the patient, at which point incident to becomes moot. [...]