Primary Care Coding Alert

With 39 percent of the family practices in the U.S. using some type of non-physician provider (NPP: nurse practitioners [NP] and physician assistants [PAs]), correctly billing for their services has become more important than ever, according to Ron Nelson, PA-C, representative to the American Medical Associations (AMA) CPT Healthcare Professionals Advisory Committee and president of the American Academy of Physician Assistants.

Incorrect billing for NPP services cannot only cause a loss of significant revenue for family practices but also can raise a red flag to auditors, which could lead to repayment of previously overpaid claims.

NPP services can be billed in one of two ways: either as incident to your family practitioners service or by using the NPPs personal identification number (PIN).

Incident to vs. NPP PIN

When a service is provided to a patient by an NP or PA and is considered incident to the physicians service (see guidelines below), it should be billed under the doctors provider number as though the physician actually performed the service. Accordingly, it is reimbursed at the same fee schedule as the family practitioner. On the other hand, Medicare will accept billing under an NPPs own PIN number, but will only typically pay about 85 percent of the physicians fee schedule.

Incident to is defined by Medicare as services or supplies that are furnished as an integral, although incidental, part of the physicians personal professional services in the course of a diagnosis or treatment of an injury or illness. In addition, Medicare outlines four requirements for conforming to incident to:

1. Services and supplies must be those offered in the physicians office or clinic. Accordingly, non-physician providers cannot bill incident to for performing hospital rounds or following up on an inpatient. If NPPs are seeing patients in the hospital, they have to bill for their services under their PIN.

2. Services must be commonly rendered without charge or included in the physicians bill. The services provided by the NPPs must be in the realm of services that the family practitioner would customarily provide in an outpatient/office setting.

3. Physicians must provide direct personal supervision to auxiliary personnel. Direct supervision encompasses two areas:

a. Physician availability: The family practitioner does not need to be in the same room as the NPP while he or she provides services, but the doctor must at least be present in the office. Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in Augusta, GA, and the American Academy of Professional Coders 1998 Coder of the Year, reminds family practitioners that if the service is billed under the physicians PIN as incident to, the doctor must be able to prove that he or she was in the office and available to the NPP. Carriers may check your schedule, she warns.

b. Patients diagnosis and treatment plan: Services billed by the NPP are called incident to because they are billed incidental to the physicians service. Accordingly, the family practitioner must have seen the patient for the first visit (i.e., it must be an established patient for the NPP to provide incident to care), established the diagnosis, and prepared a treatment plan. If changes occur after a treatment plan is set in place, the physician must be involved once again for the visit to be billed as incident to.

4. The non-physician provider must be a part-time, full-time or leased employee of the supervising physicians group practice or other entity that employs the physician. The working arrangement to allow for incident to billing is based on written agreements and common-law rules between the family practitioner and the NPP. Developing a contract is key to this relationship. Therefore, if the NPPs are working as independent freelance contractors for your family practice, they can never bill incident to your physician with his or her provider number. They must always bill using their NPP PINs in this kind of employment arrangement.

Incident to Examples Clear the Confusion

There is bound to be confusion over when your family practice should bill for its non-physician providers as incident to or using their personal identification numbers, says Nelson. Three scenarios related to established patient visits illustrate just how confusing this issue has become:

Scenario l: A 35-year-old established female patient comes into your family practice with a bad sinus condition. This is a new condition for the patient even though she has been seen at the practice previously. Thus, there is no treatment plan for this ailment. The family practitioner is present in the office but unavailable. The nurse practitioner sees the patient and determines that the condition is not serious; the patient is given a prescription for antibiotics and sent home.

Coding Solution: The patients exam should be coded from the appropriate established patient codes (99212-99215) and cannot be billed as incident to, says Quin Buechner, CPC, a coding consultant with Webster, Rogers and Company, a medical coding consulting firm in Florence, SC, whose clients include family practices. This case isnt incidental to anything because the family practitioner had never seen the patient for the sinus condition, and no treatment plan existed when the NP saw the woman, he adds.

Scenario 2: A 50-year-old established male patient with diabetes has seen the family doctor and has a treatment plan for his condition. When he needs attention for his diabetic condition, he is seen and treated by the non-physician provider while the family physician is present in the office suite.

Coding Solution: In this case, the NPP can bill incident to because the family physician has seen the patient, provided a diagnosis for the condition, and has been previously involved in the treatment plan. The family practitioner also is on-site and available to confer with the NPP if necessary.

Scenario 3: The same diabetic patient in scenario 2 comes in after a two-year absence for treatment for the disease. An update of his condition must be performed.

Coding Solution: Buechner recommends that the NP see the patient under his or her own number, but if the disease requires a new treatment plan, the family doctor should see the patient. There is too big of a time lapse between visits to use incident to, Buechner says. While there is no ruling about the two-year period, Buechner contends that after that length of time, it is doubtful that the family practitioner is actively involved in the patients treatment. He suggests you show the treatment plan to the carrier if more than two years have elapsed.

Moderate and high-level decision-making may require a doctor, Callaway-Stradley says. Medicare, however, says mid-level practitioners may bill any service that they render. She recommends that practices check with their carriers and with state regulations to determine any restrictions on the PAs and NPs scope of responsibility. Besides ensuring that mid-level practitioners are allowed to assume certain duties, Callaway-Stradley suggests family offices should take a close look at their overall practice to determine what levels of billing make the most sense. It might be more profitable to use PAs and NPs to see new patients and have them bill with their own PIN numbers because even though the billing is 85 percent, their services would allow a family practice to see more patients and the physician to see more complex cases.

Scenario 4: A final scenario involves a new patient who is found to have high blood pressure during her first visit. She is told to follow up with the PA at the next encounter. In the follow-up visit, the patient complains of blurred vision and fatigue and has a high blood-sugar level. The PA diagnoses diabetes.

Coding Solution: Although the family doctor is present in the office suite, the family practitioner has not examined the patient during that second visit or offered an opinion about the new diagnosis. Thus, the service can only be billed under the PAs own provider number, not as incident to. If the family physician wants to bill for the PAs services as incident to his or her own services, then he or she must step in and take over to make the diagnosis.

Note: Incident to cannot be used for new patients. Either the family physician makes room for the new patient and bills under his or her own name or the NPs/PAs bill under their own numbers.

Avoid Audits with Solid Documentation

Family practices cannot afford to be cavalier about not using NPP PINs, even though they are allowed by Medicare to submit services under the doctors PIN. Billing under a physicians provider number when the services were actually performed and documented by a non-physician provider can turn an audit into a nightmare. An audit examines a random sampling of claims and uses those as a basis for the entire practice. If the 100-chart sampling indicates that 20 percent of claims were non-compliant, Medicare will look back several years, apply that 20 percent overcharge to the prior claims and extract a penalty.

The best defense is taking the extra step to carefully document each visit, Callaway-Stradley says. If the circumstances are not clearly outlined, the audit decision can go against what the practice billed. When billing incident to, she recommends, the family physician should sign off on the chart while the patient is still in the office to reinforce his or her presence and the fact that the physicians name will be on the bill. If the service is billed under the family physicians provider number, coders must ensure the chart indicates the doctors involvement in the patients care, including an examination by the physician, establishment of a diagnosis, and the development of a treatment plan.