Otolaryngology Coding Alert

Remember, incident-to requires an established plan of care.

When a physician and a nonphysician practitioner (NPP) work together to perform an evaluation and management (E/M) service, it might be an incident-to service. It also might be a shared visit, and knowing the differences between the two is vital.

Why? Failure to code for incident-to or shared visits when appropriate will mean missed reimbursement that your practice deserves. Also, misusing either of these coding features could raise the antennae of payers on the lookout for miscoded services.

To get the lowdown on incident-to and shared visits, take a look at this expert input on both coding conventions.

More Knowledge on Incident-To, Shared Visits Means More $$

Both incident-to and shared visit coding are Medicare features, reminds Cynthia A. Swanson RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb. Only Medicare payers, and those that follow Medicare guidelines, are bound by incident-to and shared visit rules.

“Other commercial plans may or may not follow Medicare,” says Swanson. Additionally, third-party payers may have different requirements for incident-to and shared visits.

Best bet: Check with the third-party payer if you don’t know its incident-to and shared visit guidelines, and get those guidelines in writing for your practice.

Also, incident-to and shared visit coding can be beneficial financially for the practice. If a physician teams with a qualified non-physician practitioner (NPP) for either of these services, you may be able to code the visit under the physician’s National Provider Identifier (NPI).

This could net 100 percent of the allowed payout — when a physician is involved. If you have to report the E/M under the NPP’s NPI, you’ll only net 85 percent of the allowed amount, confirms Jan Rasmussen, CPC, PCS, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions in Holcombe, Wisc.

Danger: Do not assume non-Medicare payers (including state Medicaid payers) follow the Medicare guidelines for NPP billing. For example, Kansas Medicaid does not recognize incident-to, and requires you to bill all services the NPP performs to the NPP’s NPI. In fact, billing incident-to for an NPP’s service for a Kansas Medicaid patient is fraud. So be sure you know all your payer’s guidelines on NPP billing.

Note: Depending on your practice’s verbiage, an NPP could go by other titles, such as a mid-level provider (MLP) or advanced practice provider or practitioner (APP). You might see involvement from an MLP or APP, rather than NPP, on your incident-to or shared visit encounter forms.

Check for POS 11 Before Coding Incident-To

According to experts, there are two primary differences between shared visits and incident-to visits.

The first difference is that shared visits are for outpatient and inpatient hospital-based encounters like inpatient, observation, and ED. You would also report a visit as shared for E/Ms that take place in hospital outpatient departments or provider-based clinics. This is because incident-to rules do not apply to any place other than the physician’s office.

In other words: If the POS (place of service) is 11 (Office), you would not code for a shared visit since you have incident-to rules available to you.

Explanation: “In the hospital/outpatient setting there is no incident-to, so the only option to bill a service partially performed by an NPP in the physician’s name is shared care,” Rasmussen says. When incident-to rules are not available, you can always report shared care — also commonly called collaborative care.

Get Evidence of 2 Providers for Shared Coding

The second major difference between these two coding features is that shared visits must involve two “qualified” providers actively involved in the encounter. Incident-to only requires a single NPP to perform the E/M — but a physician must perform a supervisory role during an incident-to E/M.

You can only apply shared visit coding conventions when the following combination of providers teams up to perform an E/M service:

• Two physicians
• One physician and one qualified NPP
• Two qualified NPPs.

The providers must both see the patient, and perform a significant portion of the service, before coding the E/M. If you can submit the claim under the physician’s NPI, you’ll get 100 percent reimbursement for the E/M code. If the two providers are both NPPs, then the reimbursement rate will be 85 percent of the code regardless of whose NPI they use based on Medicare’s rules On the other hand, you might be able to code incident-to for work that an NPP does alone to care for a physician’s patient — if:

1. The provider performs the service in the office.
2. The NPP is seeing an established patient for an established problem.
3. The physician has seen the physician previously, and has put a plan of care in place, for the condition the NPP is seeing the patient for.
4. A physician is in the suite and immediately available at the time the NPP is seeing the patient.

Remember: The physician who is available in the suite does not necessarily have to be the physician who had seen the patient and put the plan of care together. The supervising physician just has to be a physician member of the practice

When a visit meets the parameters for incident-to coding, you’ll be able to report the E/M under the supervising physician’s NPI, thereby garnering 100 percent of the allowable amount for the code.

Exception: If an established patient reports for treatment of an established problem that has a plan of care from the physician, but then that patient also brings up a new problem that the NPP addresses during the encounter, you cannot bill the visit incident-to. Once the NPP treats a new problem without a plan of care to follow, you’ll need to report the visit under the NPP’s NPI.

Know All Guidelines Before Coding These Encounters

Remember, you’ll need to have a full understanding of Medicare’s rules and regulations before using these features to report E/Ms.

“The Medicare guidelines for incident-to services and shared services are complex so it is important to be sure practitioners have a good understanding of the Medicare rules and are compliant in their reporting and billing,” Swanson reminds.

Example: You can only use shared visit codes “for certain E/M service codes and places of service. A shared service cannot be reported for critical care services, consultation services, new patient office visits, or in the skilled nursing facility/nursing facility setting,” reminds Swanson.

Remember, there are no incident-to services for encounters provided in any place of service other than the physician’s office, such as the hospital outpatient and inpatient units.

Learn more: To see Medicare’s rules on incident-to coding, see: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0441.pdf. For shared visit guidelines, see: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R178CP.pdf.