Practice Management Alert

In the office setting, incident-to billing is an essential gear in a practice's reimbursement machine. Each time a nonphysician practitioner (NPP) provides services to a Medicare patient, you should be on the lookout for the opportunity to code the service incident-to the physician.

Why? Under incident-to rules, qualified NPPs can treat certain patients and still bill the visit under the physician's National Provider Identifier (NPI), allowing 100 percent of the assigned fee for the codes you report instead of the 85 percent allowance when you bill under the NPP's NPI.

But if you aren't following the stringent incident-to billing guidelines, you-re only setting your practice up for lost reimbursement and possible fraud charges. Make sure you-re capturing every dollar your NPPs deserve with these expert tips.

To qualify for incident-to billing, the physician must see the patient during an initial visit and establish a clear plan of care, reported Sharlene Scott, CPC, CPC-H, CCS-P,CCP-P, PMCC, during a presentation at The Coding Institute's multispecialty conference in Orlando, Fla.

If the NPP is treating a new problem for the patient, or if the physician has not previously established a care plan for the patient, then you cannot report the visit incident-to.

Beware: An established patient with a plan of care who comes in for a new, unrelated condition is not an appropriate case to bill incident-to. For Medicare you cannot bill new patient visits, consultations, or services provided in the hospital as incident-to services.

Tip: The physician should document in his plan of care that the patient will follow up with the NPP for monitoring of that particular episode of care. That care could be for hypertension, diabetes, cancer, or other medical conditions. When there is a new problem,however, the physician must see the patient and modify the plan of care before the NPP can provide follow-up care and bill the services as incident to the physician.

Your first step in collecting for your practice's incident-to services is determining whether the services involved -direct- supervision. This means that the physician must be in the immediate office suite while the NPP is performing the incident-to services.

Key: You should not use the term -direct- too loosely. Having the physician available by phone or having the physician somewhere on the grounds in a large facility is not acceptable by Medicare standards for billing incidentto.However, you may want to check your state's practice requirements to see if your state has different supervision requirements than Medicare. Keep in mind that even if the state require-ments are less stringent, you should always follow the stricter rules.

-The physician must be present in the office suite in order to bill as incident to,- says Nicole Martin, CPC, owner of Innovative Coding Analysis in Coplay, Pa. -He does not have to be in the treatment room itself but in the office [suite].-

Example: A nurse practitioner in your office performs the physical exam for a patient, and the physician calls in and does the history portion of the exam. The physician wants to bill this service incident-to.

This service -would be billed directly under the NP's own provider number and reimbursed at the 85-percent level,- Martin says. You cannot bill incident-to because the physician was not providing direct supervision.

Good idea: Retain physicians-work schedules on file to prove they were present when incident-to services occurred.Keep in mind that some payers like to see the name of the supervising physician in the progress notes--especially if it is a different physician than the one who wrote the care plan.

Another good idea is for the NPP to indicate on top of the note: -Dr. Smith in office supervising today.- This supports who was providing the direct supervision for that visit right in the note.

Remember: As of November 2004, the supervising physician can be different from the one who actually wrote the plan of care. The charge, and ultimately, the payment credit, must go to the physician who supervised the incident-to services on the day that the services were provided, however.

As long as a patient is an established patient with a predetermined plan of care, a nurse practitioner can submit a claim incident to a supervising physician even if that physician did not establish the initial evaluation and treatment plan. For accuracy and proper documentation, you need to record the initial evaluating physician's name and NPI in boxes 17 and 17A of the CMS 1500 form when another physician provides the supervision for subsequent office care.

If the NPP service doesn't fit incident-to regulations,that doesn't mean you have to forego payment all together. If you do not bill an NPP visit incident-to the physician,then you should code the service under the NPP's NPI number. Expect Medicare to reimburse you at 85 percent of the global, or full, fee.

Alternative: You can bill for a PA's time, just not under any of the doctors. -PAs may bill under their own NPI,- Martin explains. -This would also depend on the payer. Some payers do not recognize mid-level providers.-

As stated above, Medicare will reimburse 85 percent of the global fee for NPP services that do not meet incident-to rules. Private or commercial payers, especially if they do not recognize incident-to rules or do not credential NPPs, usually pay full physician fees for NPP services provided the physician is available for -general- supervision. This is irrespective of the physician's presence in the office or whether the patient is established, new, or a consultation.

Important: If you spent hours poring over the 23-page incident-to guidelines that CMS had planned to implement on June 2, make sure you forget everything you learned, at least for now. On the very day that practices were supposed to start using the new incident-to guidelines, CMS rescinded Transmittal 87, noting that the document -will not be replaced at this time.- So, for now,stick with the old rules.

Careful: For other third-party payers, you should find out what their rules are. For example, Kansas Medicaid does not follow Medicare incident-to rules and expects NPP's to bill under their own numbers whenever they see a Medicaid patient. Then, they pay 75 percent for the service.