Practice Management Alert

Take this quiz to see if you should be hitting the incident-to billing books

Each time a nonphysician practitioner (NPP) provides services for a Medicare patient, you should be on the lookout for the opportunity to bill the service incident-to the physician. But if you don't follow Medi-care's strict guidelines for incident-to billing, you-ll only see partial payments and denials. Take this quiz to test your NPP knowledge.

Beware: Your billing will be noncompliant if you continue to bill the NPP services under the physician's NPI without following Medicare's rules. If you cannot bill for the NPP's in-office service under incident-to guidelines, you have the alternative to bill the NPP under his own NPI/PIN and receive 85 percent of the physician fee schedule allowance.

Question 1: One of your practice's nurse practitioners (NP) sees an established patient whom the physician has been treating for diabetes. The physician has seen the patient recently and has established the diagnosis and initiated treatment or a care plan. The NP performs a follow-up history and examination and continues the prescribed treatment. The physician is in the office suite, but does not see the patient. How should you code this encounter?

Question 2: A physician assistant (PA) from your office sees a patient in the hospital whom your physician admitted the day before. Can you report this visit incident-to the physician?

Question 3: A new patient complaining of recurrent headaches comes to the office. One of your NPPs treats the patient and establishes a care plan for migraines. Can you bill this service incident-to the physician who was in the office suite at the time of the appointment?

Question 4: An established patient with abdominal pain comes to the office. One of your NPPs treats the patient and establishes a care plan for irritable bowel syndrome, without conferring with the physician. Can you bill this service incident-to the physician who was in the office suite at the time of the appointment?

Question 5: Your physician leaves the office to perform rounds at the hospital. The nurse practitioner sees one more patient for a gardisal injection, which was planned by the physician. The patient is established with the physician, and the NP follows the established plan of care. Can you report this service as incident-to?

Answer 1: You should report an established office visit, depending on the level of service -- most likely a 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) or 99213 -- under your physician's name and PIN/NPI. You-ll be paid 100 percent of the E/M code's fee.

Because the patient had a plan of care and is not new or undergoing status change, plus the physician is in the office suite, the NP can provide the service and you can use the physician PIN/NPI, filing the services incident-to the physician with Medicare.

Answer 2: No. Never report incident-to services in a hospital setting, either outpatient, inpatient or in the emergency department. Medicare only allows billing incident-to in the physician's office.
 
Answer 3: No. In this example, the patient is new to your office and received treatment for a new problem, meaning the NPP was not following an established care plan. Therefore, you should report the encounter using the NPP's UPIN/NPI. Anytime the NPP sees a new patient independently for a new problem, you should code for the service with her UPIN/NPI.

Answer 4: No. In this example, although the patient is established, the NPP saw her for treatment for a new problem, meaning the NPP was not following an established care plan and developed one without the physician. Therefore, you should report the encounter using the NPP's UPIN/NPI. Anytime the NPP sees an established patient independently for a new problem, you should code for the service with her UPIN/NPI.

Answer 5: You can't report this service as incident- to. To bill incident-to the physician, you must also be sure that the NPP provided the service under the -direct supervision- of a physician. To meet -direct supervision- requirements, the physician must be present in the office suite and immediately available to render assistance if necessary.  However, the physician does not have to be physically present in the exam room with the NPP, and the supervising physician does not have to be the same one who established the patient's plan of care.

Double-Check Private-Payer Rules

Keep in mind that although Medicare very specifically spells out its rules for NPP billing, private payers do not necessarily provide the physician their rules. You should ask your private payers to provide their procedures for billing NPP services in writing.

Caution: Remember that you can only bill Medicare for NPP services if they are permitted within the NPP's state license. Make sure you know what your state allows your NPPs to do within the practice so your NPPs do not overstep their scope of practice.
 
Answers reviewed by Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.