Avoid the Pitfalls of Incident to Versus Direct Billing
Published on Fri Sep 01, 2000
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 [...]
