Part B Insider (Multispecialty) Coding Alert

Question: If our physician and nonphysician practitioner (NPP) are in contact over the phone — but are in different buildings — can our practice still bill “incident to” on Medicare claims?

Codify Subscriber

Answer: No. The Centers for Medicare & Medicaid Services (CMS) stipulates an NPP must be working under “direct supervision” of a physician to bill incident to. The supervising physician cannot be across the street, three blocks away, or available via cell phone. If there is no physician physically present in the office suite during the time of the NPP service, the service must be billed to Medicare under the NPP’s name and national provider identifier (NPI).

Breakdown: According to Medicare’s direct supervision guidelines, the supervising physician:

• Must be physically present in the office suite
• Need not be physically present in the treatment room
• Must be readily available to provide assistance and direction to the NPP
• Need not actually see the patient

“This means for the duration of the service if the supervising practitioner does not satisfy all requirements, the supervision component has not been met and should be billed with the NPP’s NPI. Expected reimbursement is 85 percent,” explains Kelly Loya, CPC-I, CHC, CPhT, CRMA, associate partner at Pinnacle Enterprise Risk Consulting Services LLC in Charlotte, North Carolina.

Documentation: As a best practice, the NPP should describe in the documentation the supervising physician was in the suite at the time of the service. This will clearly illustrate that the supervision requirement has been met. “In the event this is not stated clearly, supervision must be supported in some other manner and consistently verifies the presence of the qualified physician to provide the necessary supervision,” Loya says.

Important: State laws sometimes lack clarity in supervision guidelines. However, CMS directly states that Medicare’s federal incident-to rules supersede any state’s rules — and the feds’ mandates are often more restrictive, experts say.

Some state boards may only require general supervision, or the physician be available by phone, in order to consider an NPP “directly” supervised. Don’t confuse this clinical practice guideline with the reimbursement guideline for services billed under the incident-to provision.