Pediatric Coding Alert

Hospital-based incident to? Not so fast.

Many pediatric practices have mid-level providers on staff who can bill their services incident-to the physician and, for many payers, collect 15 percent more than if they billed using their own provider numbers. However, the rules for incident-to can be tricky. Check out the following five questions on this topic, with answers that will ensure that your services stay on the straight and narrow.

Just the Facts

Question 1: How does “incident to” billing work?

Answer 1: Under incident-to rules, qualified non-physician practitioners (NPPs) such as nurse practitioners and physician assistants (NPs and PAs) can treat certain patients and still bill the visit under the physician’s provider number, bringing in 100 percent of the assigned fee (i.e., what the payer would have allowed if the physician had personally performed the service).

To qualify for incident-to, you must first ensure the visit meets a few criteria, as established by the Center for Medicare and Medicaid Services:

1.     The NPP performs the service in a physician’s office.

2.     The NPP performs the service within the scope of her practice and in accordance with state law.

3.     The physician should establish the care plan for the new patient to the practice or any established patient with a new medical condition. NPPs may implement the established plan of care.

4.     The physician must be on site (direct supervision) when the NPP is rendering the service.

The above rules are based on Medicare requirements, but most private payers follow that lead when creating incident-to rules. Cigna’s policy, for instance, states, “For services to be considered as incident to a physician’s professional service, 1) they must be rendered under the physician’s immediate personal supervision by his/her employee, 2) they must be an integral, although incidental part of a covered physician’s service, 3) they must be of kinds commonly furnished in physician’s offices, and 4) the services of nonphysicians must be included on the physician’s bills.”

Because many policies require that the NPP can’t bill incident to for a new diagnosis, keep in mind that in most cases, the physician must have seen the patient during a prior visit and established a clear plan of care. If the NPP is treating a new problem for the patient, or if the physician has not established a care plan for the patient, then most plans won’t allow you to report the visit as incident-to.

Check supervision: In addition, when meeting the requirements for a follow-up to an established plan of care, if the physician does not directly supervise the NPP, the incident-to rules do not apply. Direct supervision means a supervising physician must be immediately available in the office suite.

Don’t Panic If You Don’t Meet the Regs

Question 2: We were about to bill incident to and then realized the physician had gone out to lunch while the PA performed the service. Do we have to write off the claim?

Answer 2: If you find the service does not meet incident-to billing requirements, you don’t have to forego payment altogether in many cases. If a credentialed NPP provides the service, you can usually bill under his own provider number. In that case, you’ll usually receive between 65 and 85 percent of the normal allowance found in your insurer’s pay schedule. Medicare set the bar by paying 85 percent of the physician fee schedule for NPPs billing under their own NPI.

Exception: If a member of your auxiliary staff, such as a medical assistant (MA), provides a service when there is no direct supervision, you cannot bill for the service.

Don’t Expect Hospital Incident-to Pay

Question 3: Can we report incident to services for hospital place of service claims?

Answer 3: A major key to incident-to billing is that most insurers won’t allow you to bill this way in a hospital setting.

In addition, any NPP providing incident-to services must represent a “direct financial expense” to the physician, according to Medicare guidelines that most private insurers adopt. This means that the NPP must be an employee or independent contractor of the physician’s practice.

Doctors Can’t Bill Incident-to

Question 4: I have a case where one physician (physician A) in my practice covered an established patient office visit for another physician (physician B) in the practice because physician B had to run across the street to see a patient in the hospital. They want me to bill the office visit incident-to physician B even though he was not in the office at the time. Is this legit?

Answer 4: You should not report this service incident to physician B. Incident-to billing doesn’t apply between two physicians. You cannot bill services provided by one physician under another physician’s name or number. Billing under the name of a physician who did not perform the service could lead to allegations of false claims submissions. In this case, physician A should bill for the service.

Maintain Pristine Documentation

Question 5: What should incident to documentation include?

Answer 5: Ensure that the documentation clearly notes who performed the service. Even if your claim has the doctor’s number on it, the actual medical record should be signed by the NPP and note that the NPP was the practitioner. In addition, ensure that you have proof that a supervising physician was actually on site on the date of service. More than one incident to claim has been denied because auditors realized a physician was on vacation while he was purported to be overseeing several NPPs.