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.

Note: Currently, audiograms may be performed in most states by non-audiology staff because there are no credentialing criteria for administering these tests. Please check your own states requirements.

Incident to should be billed only when the NPP provides and documents the service, and a physician is in the office suite. In many states, the physician present also must sign off on the NPPs documentation, noting that it has been reviewed and accepted. If no physicians are present, incident to cannot be billed. If the supervising physician is away and another doctor is in the office, the NPPs services can be billed incident to only with the name and PIN of the physician present when the service is performed.

Service Under a PIN

Another important restriction is that the care of new patients or patients with new problems by NPPs cannot be billed incident to, and audiologists, NPs, PAs and certified registered nurse (CRNs) should bill such services under their own names and Medicare PINs. In 1998, Medicare issued PINs to NPs, PAs and CRNs as limited license professionals. Audiologists, too, are issued PINs and can bill under their own names.

When seeing new patients, or established patients with a new problem, assuming there are no scope of practice restrictions or other laws or licensing guidelines in the specific state preventing these kinds of encounters, NPs and PAs can bill under their own names and PINs and will receive 85 percent of the amount the physician would get. Some states require that the physician be accessible, and a few require that the physician be in the clinic if a patient is being seen by a PA, NP or CNS.

Finally, if the NPP is not an employee or leased employee but is an independent contractor trying to build his or her own practice, the physician practice needs to clearly define, possibly with a contract, how services will be billed before the NPP is hired. Otherwise, the NPP may be under the impression that he or she is working on a production for payment basis, while the office is billing incident to. This can be a problem because Medicare may not consider the NPP who is paid based on the number of patients seen as an employee. Medicare requires that employers keep a written contract with employees on file, Blackwell says.

NPP Benefits Outweigh Loss

Some otolaryngologists chafe at the loss of 15 percent if, for example, they cannot bill incident to and the practice has to bill under the NP or PAs own name and PIN. But this may be a pennies-wise, pounds foolish approach, Cobuzzi says.

Using NPPs to ease the physicians overflow of patients should be encouraged, whether incident to can be billed or not, Cobuzzi says. Physicians should consider letting go of their case load and allowing their NPPs to see the overflow of patients. In a managed care world, it is hard for the physicians to see every patient that walks through the door.

In any event, Medicare has hinted it may soon dramatically tighten incident to requirements or eliminate them altogether. Incident to is ripe for abuse, because it is impossible to determine that the physician did not see the patient when billing such services. Seeing a patient when the physician is not in the office and billing it incident to to collect 100 percent instead of 85 percent of the service fee is fraud, but Medicare has no way of actually knowing unless they come in and perform an audit.

Therefore, some coding specialists speculate, based on correspondence from HCFA officials, that within approximately 18 months, the only incident to service that will still be permitted will be 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) when it is billed by a registered nurse, licensed practical nurse, or other trained employee. Physician assistants, nurse practitioners, audiologists and other NPPs and limited license providers, some believe, may soon be required to bill only under their own names and PINs.

This should not, however, deter physicians from using NPPs to lessen their burden and free them to perform more procedures. Using NPPs enables the physician to see more patients and perform more procedures because the NPP will see many of the followup patients, Cobuzzi says. Doctors must also be able to trust and give up some control with regard to patients. Otherwise, having these staff is very expensive. With this in mind, the 15 percent that is lost billing under the NPPs own name and PIN is not a lot of money, she notes.

Otolaryngology office staff, however, also should take note that billing under the NPPs own provider number comes with its problems, Cobuzzi says. If an NP or PA bills incident to one day (because a physician is present) and uses his or her own name and number the following day, staff can confuse the two and bill both days under the physicians number. This could be considered fraudulent.

Even though most commercial carriers follow Medicare guidelines, there usually is nothing in writing. Consequently, Cobuzzi advises practices to try to get a statement from carriers that spells out which NPPs they consider credentialed, or, in the absence of that, whether they follow Medicares incident to guidelines. The statement also should note how NPP services should be billed. This will eliminate possible audits.

Note: Emily Hill, PA, a coding and reimbursement specialist in Wilmington, N.C., and a member of the American Medical Associations Relative Value Update Committee, Correct Coding Policy Committee and CPT-5 Project, contributed to this article.