Pulmonology Coding Alert

Address the issue early of how to bill the work of a non-physician practitioner (NPP). If you bill the work of the NPP as incident to the work of the physician, the practice is paid 100 percent of the physicians fee. But when the work is billed directly under the NPPs identification number, the practice receives only 85 per cent. Coders need to know about incident to and direct billing even though it isnt a coding issue per se, says Quinten A. Buechner, MS, M.Div., CPC, president of ProActive Consultants, LLC, in Cumberland, Wis. If theyre processing claims that dont meet the criteria, theyre helping to perpetuate fraud or at least abuse. Therefore, the coders need to know how these regulations fit together so they can help keep the practice out of trouble.

Regulations say you can bill the same NPP differently from one patient to the next, but there are times when you are allowed to bill incident to and when you arent. The key is that the Health Care Financing Administration (HCFA) will pay only for services performed by ancillary personnel if the services are a true extension of the physicians work, says Robert Wanerman, JD, MPH, a healthcare attorney with the Washington, D.C. law firm of Arent, Fox, Plotkin and Kahn. If the doctor has someone else performing a service he or she would have done, then that service can be billed at full price as though the doctor had performed it himself.

But it isnt quite as simple as it sounds. This should be a fairly easy concept, says Buechner. There is so much history involved that people get mixed up quickly, and HCFA doesnt do much to lessen the confusion.

Medicares definition of incident to is the standard medical model with the physician at the top and everything flowing from his or her orders. Medications, treatments and other interventions all are incident to the doctors decisions and authority.

Criteria must be met for billing the incident to at the full rate, and the physician must first perform a professional service. Then the following rules apply for incident to billing:

1. The NPP has to represent an expense to the practice. The costs of the NPP must be carried by the practice. For example, a physician cannot have a hospital-based nurse provide a service for a patient and bill it as incident to the physicians orders. What happens when a practice leases equipment and the contract includes the services of an operator? In this case, the operator doesnt represent an additional expense to the practice, so his or her services cannot be billed incident to.

2. The NPP has to be an employee of the practice (either direct or leased). Its easy to see when someone working directly for the practice is an employee. If the practice writes the employees payroll checks and pays the taxes, you should be all right. Where it gets a little dicey is when a person is leased through an agency, says Wanerman. The best rule of thumb is to ask yourself if youre able to exercise the same amount of control and supervision over the leased employee as you would over those who work directly for you. If you do, you may bill the leased employee incident to without a problem.

3. The physician must be in the office and immediately available, and must supervise the NPP.
HCFA says the physician must be present in the office suite where the NPP is providing care, even though the physician may be seeing other patients or attending to paperwork.

Incident to rules require a physician to see the patient first and outline a plan of care. A good care plan will include the information that the NPP will see the patient for follow-up care. To maintain incident to billing, the doctor has to see the patient every so often and make notations in the care plan. Most carriers accept doing this every third or fourth visit, says Buechner.

Potential problems may arise because HCFA sets minimum requirements for supervision, but defers to the states to define the relationship. Thus, something that is perfectly legal in one state could be considered fraud in another. You not only have to keep a close eye on what HCFA says, but also know how your states rules affect your billing, says Buechner. If your state says that an NPP may not practice independently of a physician, then your only option is to bill incident to. Remember to make sure that services given by the NPPs are legal under the laws of the state where they are practicing.

Another concern is the states definition of supervision. Some states say any physician in the group can provide supervision for the NPP, which also is acceptable to HCFA. Other states, however, require that a specific doctor be assigned to an NPP. In this case, only the doctor assigned to the NPP may bill for incident to services.

When the states say that any physician may supervise the NPP, the practice should still be concerned about which doctors signature is on the claim form. The form says that the person who signs it certifies that he or she personally supervised the visit. There are some practices who have a doctor of the day sign all of the claim forms for that day as the physician the NPPs are working incident to, notes Wanerman. If there is an audit, the auditor may find it hard to believe that all of the days orders were done under the supervision of that one physician.for this reason.