Practice Management Alert

Medicare is the only payer that consistently recognizes incident-to

If you don't know all of the situations when you should bill for services provided incident-to a physician, your office could miss out on justified reimbursement.

How? When a nonphysician practitioner (NPP) performs a service incident-to a physician, then the office can bill under the physician's Medicare number and secure 100 percent reimbursement.
 
If, however, the NPP's services are not provided incident-to the physician, you must bill under the NPP's number, which garners you 85 percent reimbursement for the same service.

When deciding whether a service can be billed incident-to a physician, you must ask yourself the following questions.

If you can answer -yes- to all of them, you should be able to report the service incident-to rather than under the NPP's Medicare number, thus raking in 15 percent more revenue for the service:

- Is the physician present and available in the office? Medicare says the supervising physician must be -present and available in the office- when the NPP sees the patient in order to bill incident-to.

-Present and available in the office means that there is direct [physician] supervision, which means that the physician is physically present and readily available in the office suite,- says Chris Felthauser, CPC, CPC-H, ACS-OH, ACS-OR, PMCC, medical coding instructor for Orion Medical Services in Eugene, Ore.

So if the physician is in the next examining room at the facility, you can still bill for incident-to services. If he is off-site and only available by phone, however, bill under the NPP's number.

- Is the patient following an established plan of care? If the physician has not established a plan of care, incident-to billing is impossible.

-The whole meaning of incident-to is that this is an established patient following a prescribed course of treatment by the physician and is presenting for follow-up in the office,- Felthauser says.

Consider this example: An NPP sees an established patient in the office to check on the patient's hypertension. The NPP performs a level-two evaluation and management service on the patient. The physician is in the office supervising but does not see the patient.

In this instance, -incident-to requirements were met; this is an established patient with an established problem and plan of care, and the physician is in the office. You may bill incident-to the physician using the physician's UPIN/PIN for the NPP's service,- says Jennifer Schmutz, CPC, health information coder with Neurosurgical Associates LLC in Salt Lake City.

On the claim, you should report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making) incident-to the physician.

Remember: Any services the NPP provides incident-to the physician -must also fall under the scope of licensure for the NPP in whatever state she is practicing in,- Felthauser says.

- Did the NPP perform the services in the medical office? Incident-to services are -commonly furnished in physicians- offices or clinics,- according to CMS. This means that reporting incident-to services in a hospital setting is typically frowned on.

The only time a hospital setting warrants incident-to billing is when the physician's office is -confined to a separately identifiable part of the facility and cannot be construed to extend throughout the entire facility,- CMS says. For instance, if a privately practicing internist rents a small wing of a large hospital to practice, Medicare will accept incident-to billing for this practice. In addition, any NPP providing incident-to services must represent a -direct financial expense- to the physician, CMS says. This means that the NPP must be an employee or independent contractor of the supervising physician's practice.
 
- Have you noted incident-to services in the medical record? You must have very clear documentation when billing incident-to; you want to make it clear to Medicare that you have met the parameters of incident-to billing through your documentation.

When you bill an incident-to claim, Felthauser recommends that you:

- document in the chart that you are providing incident-to services.
- document which NPP is providing incident-to services, and for which physician.
- have the NPP review and sign the chart. Then, have the physician sign to -show that he has approved what is in the chart,- Felthauser says.

-  Does the payer recognize incident-to billing? While Medicare carriers will pay for services provided incident-to a physician, the majority of private payers will not. Felthauser says he has seen a few private carriers that will pay incident-to, but they are rare.

Best bet: Check your private-payer contracts or contact a carrier representative to see if any of them will accept incident-to billing. If they do recognize incident-to, be sure to ask if their rules for reporting the service mirror Medicare-s, Felthauser says.