Pediatric Coding Alert

How to turn 'incident-to' services from confusing to profitable

The U.S. Health and Human Services Department's Office of Inspector General (OIG) continues to focus on services and supplies reported "incident-to" physicians' services as a part of the agency's Work Plan for 2003. Continued interest in these areas reveals the ongoing difficulty physicians and coders experience when documenting and reporting these services.
 
The agency will also continue to scrutinize all services billed for nonphysician practitioners (NPPs), noting that physicians are reporting such services four times as often in recent years as previously. Here again, providers must take care that NPP practice employees provide incident-to services within the parameters established by CMS and that NPP services meet scope-of-practice requirements.
 
The eligibility of NPPs to report incident-to varies widely from state to state, but the list below indicates some of the more commonly recognized NPPs.

NPPs allowed to report incident-to services (within their scopes of practice):

  Clinical Nurse Specialists
  Clinical Nurse Midwives
  Clinical Psychologists
  Clinical Social Workers
  Nurse Practitioners
  Occupational Therapists
  Physician Assistants
  Physical Therapists
  Speech Pathologists  Practices must comply with the intricate guidelines that regulate incident-to billing because repayment and fines can be steep. The good news, however, is that you can turn these OIG lemons into lemonade. By understanding and following the guidelines below, practices can increase their payment for incident-to services and avoid difficulties with the OIG. Recover an Additional 15 Percent Medicare's reimbursement policy for incident-to services allows you to report certain services rendered by NPPs under the supervising physician's number. The result: You receive reimbursement for those services at 100 percent of Medicare's allowable Physician Fee Schedule instead of 85 percent of the fee schedule allowed under the NPP's number, says Judith Richardson, RN, MSA, CCS-P, a senior consultant with Hill & Associates in Wilmington, N.C.
 
Keep in mind that while NPPs can handle more in-depth services and bill incident-to, state regulations determine the allowed services they may perform. You should make sure your licensed NPPs follow the local regulations for prescribing, ordering tests, and performing other services. Play by the Rules - Win the Game Medicare has four incident-to guidelines:

  The service(s) must be an integral, although incidental, part of the physician's professional service.   "This makes it clear that the doctor must be involved in the patient's care," says Michael Powe, director of health systems and reimbursement policy for the American Academy of Physician Assistants (AAPA). "The physician must personally treat, diagnose and develop a treatment plan on the patient's first visit to the practice for a particular medical problem. Subsequent care and services can then be delegated, and billed incident-to."

The supervising physician must also personally treat and diagnose established patients who are being seen for a new problem or condition. Be aware that services by a NPP [...]