Eli's Rehab Report

Nugget: When billing incident to it is possible
to increase the reimbursement from 85 percent to
100 percent of the doctors fee.

Physical medicine and rehabilitation practices that use non-physician providers, such as nurses, physicians assistants, and physical therapists, may be able to boost reimbursement by using the incident to designation, which if used properly reimburses at 100 percent of the physicians rate for some outpatient services.

According to Medicare and many other payers, some services provided by non-physician practitioners are considered part of, or incidental to, the physicians personal professional services. If the providers meet the payers pre-specified incident to guidelines, coders can assign CPT Codes and report the services to the payers using the physicians own personal identification number (PIN). Under Medicares current guidelines, incident to services are usually reimbursed at 100 percent of the physicians fee schedule, as if the physician performed the services him- or herself.

Note: There is an exception for mental health services, which are reimbursed at 50 percent.

We just started using incident to, says Dawn Fortuna, who handles the billing for Paul Rohner, MD, a practicing physiatrist in Brooklyn. We hired a physical therapist (PT) who was billing incident to when she worked at another practice, and she is helping us out with it while were learning.

The Medicare Carriers Manual, (MCM) section 2051, dictates Medicares guidelines for billing incident to services:

The physician must be on-site at the time of treatment.

The physician originally saw the patient for the first visit to the office or clinic.

The physician must see the practices established patients for any new medical problems.

Note: These guidelines are for incident to services delivered in an office or clinic; Medicare does not recognize inpatient services provided in a hospital or nursing facility as incident to.

Preparation is Better Than Reparation

Fortuna submitted a bill to Medicare for a physical therapists evaluation of a patient with a new prosthetic using 99213 (established patient, office or other outpatient visit), billing it as incident to, even though the doctor didnt see the patient that day, says Fortuna. But he was in the office, so we knew it would be okay. When we found out that Medicare was paying us for it, the doctor said we should find out what other carriers were saying about incident to, but were finding that a lot of them dont recognize it.

William J. Mazzocco, Jr., PA-C/RN, president of Medical Administrative Support Services in Altoona, Pa., and a national speaker on the integration of non-physician practitioners, recommends that billers get in touch with their insurance companies before attempting to use the incident to designation. Preparation is better than reparation, says Mazzocco. If youre not sure whether your carriers recognize incident to services, you should contact the 10 or 12 standard carriers that represent the bulk of your practices income and ask whether they acknowledge incident to billing. If you dont ask, they wont necessarily tell. If your contract says physician may not delegate or physician only, you know already that your payer wont recognize incident to billing.

Some private insurance carriers will recognize only nurse practitioners and physicians assistants as being able to perform incident to services, says Mazzocco. Some insurance companies will have no stipulation regarding who performs the services. And then some carriers say theres no such thing as incident to.

Many carriers are putting an artificial ceiling on incident to, says Mazzocco, allowing it only for certain levels of service, such as up to 99213. So its very, very important to find out what your insurance company dictates about incident to, and be sure to get everything in writing.

Mazzocco warns billers against avoiding the use of incident to by upcoding non-physician services. Some practices will say, Nurses cant do the incident to with our carrier, so well only have nurses bill for the 99212 (established patient office or other outpatient visit for the evaluation and management of an established patient), and because thats a lower code, it wont give us a problem. But the opposite is true, because if the insurance company sees that youre billing the same code consistently, theyll wonder why you dont have the bell-shaped curve that most practices bill, with some lower-fee services, some higher-fee services, and some in the middle. Not every patient can be a 99212.

Physicians on Rotating Schedules

Practices whose doctors rotate may be confused about Medicares guideline that the physician must be on-site when incident to services take place. Our office has two locations, says Fortuna, so we have to be careful about whether each patients specific doctor is in when the PT bills for incident to.

The MCM clarifies this issue, and states, In a physician-directed clinic where responsibility is shared for supervision of medical services performed by employees of the clinic, the physician who orders a service is not necessarily the same physician who provides direct personal medical supervision while the service is performed.

It does not have to be the same physician, says Mazzocco, as long as the physician is an employee of that practice.

The MCM states, Coverage of services and supplies incident to the professional services of a physician in private practice is limited to situations in which there is direct personal physician supervision. This applies to services of auxiliary personnel employed by the physician and working under his/her supervision, such as nurses, non-physician anesthetists, psychologists, technicians, therapists, including physical therapists, and other aides.

Coders should note that sections 2150 through 2190 of the MCM detail coverage instructions for the various non-physician practitioner services, including educational and employment requirements for personnel.

Documentation is key when billing incident to, says Mazzocco. If someone from the insurance company comes into your office, all they have to do is look at the doctors schedule and the offices appointment book to find out if the doctor was there that day. So keep all of your records and carefully document everything.