Pulmonology Coding Alert

Question: Is there any circumstance in which a group can bill all services and all providers (including other physicians) under just the medical director? I know we can bill nonphysician practitioner (NPP) services incident to another physician. What about to other physicians?

California Subscriber

Answer: No, you cannot always bill services for all providers under a group's medical director. One reason is because you may not bill one doctor incident to another doctor. Incident to rules don't apply here because they pertain to care rendered by an NPP incidental to the plan of care established by the physician. The NPP must have an identifiable relationship with the physician (such as a leased or direct employee of the group practice).

Bottom line: It is never acceptable to bill services provided by one physician under another physician's name or national provider identifier (NPI). Physician billing under the name of a physician who did not perform the service will lead to denials or refund requests with citations that the service was "reported under the wrong provider's name." Report the service under the NPI of the performing physician.

You can, however, report NPP services incident to a physician instead of the NPP's using the physician's NPI if the visits meet all the requirements of incident to services. The NPP could be a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist -- as long as the NPP meets state and federal guidelines to provide the service.

The NPP must be "licensed by the state under various programs to assist or act in the place of the physician," according to the Medicare Benefit Policy Manual, Chapter 15.

Best bet: Check your state and local Medicare regulations for NPP qualifications. If the NPP does not meet one or both sets of guidelines, don't bill incident to for physician-level services (such as 99212-99215, Office or other outpatient visit ...).

Keep in mind: In order to bill the service under the medical director's NPI, there has to be a plan of care for the patient's condition (and the plan of care may have been developed by the patient's regular physician and not necessarily the medical director). Plus, the medical director must be physically on site in the office suite when the NPP is providing the service you are billing. However, if the patient's attending physician is also present in the suite during the service, it is always advisable to report the service under the attending physician's NPI instead of the medical director. This will prevent patient complaints and questions about the service being billed under a physician that the patient has never met.

-- The answers to the Reader Questions and You Be the Coder were provided and reviewed by Alan L. Plummer, MD, professor of medicine in the division of pulmonary, allergy, and critical care at Emory University School of Medicine in Atlanta; and Carol Pohlig, BSN, RN, CPC, ASC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.