Part B Insider (Multispecialty) Coding Alert

Don't take unnecessary risks for 15 percent more pay

Do you know how the incident to rules apply to diagnostic services? The answer is, the incident to rules don't always apply to these services, but many medical practices aren't aware of that. And based on new scrutiny directed toward incident to claims, you should know the incident to rules inside and out. The OIG's recent discovery that unqualified non-physician practitioners (NPPs) performed 21 percent of incident to services is sure to have MACs scrutinizing your incident to claims very carefully (see page 217 for details on the OIG's report).

Although the OIG would like to apply a quick fix to the incident to billing issues that practices have faced, CMS acknowledges that appending an "incident to modifier" wouldn't be a cure-all. "A modifier or series of  modifiers might at some point be part of an overall solution, but right now it isn't the only solution," says Joan Gilhooly, CPC, PCS, CHCC, president of Medical Business Resources. "CMS first needs to debunk all the myths and misunderstandings about incident to."

For instance: Many practices believe that as long as they meet the minimum requirements of incident to (the physician is on-site and sees patients for any new problems), they can bill all NPP services incident to and collect their extra 15 percent reimbursement. In many cases, "physicians feel as long as they can just simply peek in or sit somewhere nearby, they're covered by these rules, unaware that there is more to it than just letting events happen within an office (or hospital) setting," suggests Leslie Johnson, CPC, coding supervisor for Duke University Health System and owner of the billing and coding Web site AskLeslie.net. "There needs to be a certain level of involvement that takes more than a passing glance.

Coders and billers are confused. They may not know the rules, and may be confused by the terminology 'incident to.'"

It's impossible to tell whether CMS might eventually decide that an incident to modifier would be useful after all. But other solutions might prove just as helpful.

"CMS should publish a comprehensive list of services for which the incident to provisions don't apply," Gilhooly suggests.

For example: Many practices aren't aware that the regulations exclude flu (G0008) and pneumonia (G0009) vaccine administration from the incident to requirements, but require that incident to rules be met for the hepatitis vaccine (G0010) when covered, Gilhooly explains.

Plus: The incident to rules don't always apply to diagnostic tests, which are governed by separate supervision requirements. "In the Medicare Fee Schedule, you can find the supervision indicators that describe what Medicare requires for diagnostic tests," Gilhooly says.

For instance: If a patient gets a foot x-ray, "the ordering physician has seen the patient to establish medical necessity for the order, but because only general supervision is required for a foot x-ray, the supervising physician doesn't even have to be in the same town when the x-ray is performed," Gilhooly says. On the other hand, some tests require "direct" supervision, meaning the doctor has to be in the office suite, or "personal" supervision, meaning the physician has to be in the exam room.

With increased scrutiny on incident to services, it's important to document accurately and discontinue any "inappropriate flexibility" you may have taken advantage of in the past, advises Quinten A. Buechner, MS, MDiv, CPC, ACS-P/GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland,Wis.

Bottom line: Don't report your licensed NPP's services (nurse practitioners, physician assistants, etc.) under the physician's identification number unless you're confident that you're billing incident to properly.

You'll collect 15 percent less of the service's reimbursement by billing under the NPP's own NPI, but you'll be billing properly.

Note: You must bill the services of non-licensed NPPs, such as medical assistants, nurses, etc., as incident to since these employees cannot be credentialed with their own NPIs. To read the OIG's report on incident to billing, visit www.oig.hhs.gov/oei/reports/oei-09-06-00430.pdf.