Pulmonology Coding Alert

Incident-to rules don't always apply to diagnostic services, but many medical practices aren't aware of that. And based on new scrutiny directed toward incident-to claims, you should know the incident-to rules inside and out.

The Office of the Inspector General's (OIG's) recent discovery that unqualified nonphysician practitioners (NPPs) performed 21 percent of incident-to services is sure to have Medicare scrutinizing your incident-to claims very carefully.

Although the OIG would like to apply a quick fix to the incident-to reporting issues that practices have faced, CMS acknowledges that appending an "incident-to modifier," as done in the distant past, wouldn't be a cure-all.

"A modifier or series of modifiers might at some point be part of an overall solution, but right now it isn't the only solution," says Joan Gilhooly, CPC, PCS, CHCC, president of Medical Business Resources. "CMS first needs to debunk all the myths and misunderstandings about incident-to."

The presumption: Many practices believe that as long as they meet the minimum requirements of incidentto (the physician is on-site and sees patients for any new problems), they can report all types of NPP services incident-to and collect their extra 15 percent of Medicare reimbursement. In many cases, "physicians feel as long as they can just simply peek in or sit somewhere nearby, they're covered by these rules," unaware that there is more to it for the different types of services these offices perform, suggests Leslie Johnson, CPC, coding supervisor for Duke University Health System and owner of the billing and coding Web site AskLeslie.net.

The reality: "There needs to be a certain level of ongoing involvement," Johnson says. "Coders, billers, and physicians are confused. They may not know the rules, and may be confused by the terminology 'incident to.'"

Not All Codes Apply to Incident-To

It's impossible to tell whether CMS might eventually decide that an incident-to modifier would be useful after all. But other solutions might prove just as helpful. "CMS should publish a comprehensive list of services for which the incident-to provisions don't apply," Gilhooly suggests.

For example: Many practices aren't aware that the regulations exclude flu (G0008) and pneumonia (G0009) vaccine administration from the incident-to requirements, but require that incident-to rules be met for the hepatitis vaccine (G0010) when covered, Gilhooly explains.

Plus: The incident-to rules don't always apply to diagnostic tests, which are governed by separate supervision requirements. "In the Medicare fee schedule, you can find the supervision indicators that describe what Medicare requires for the technical components of diagnostic testing," Gilhooly says.

For instance: If a patient gets a chest X-ray, "the ordering physician has seen the patient to establish medical necessity for the order, and because only general supervision is required for a chest X-ray, the performing physician doesn't even have to be in the same town when the X-ray is performed," Gilhooly says. Note that the "ordering" physician and the "performing" physician may or may not be the same individual in certain circumstances.

On the other hand, some tests require "direct" supervision, meaning the doctor has to be in the office suite, or "personal" supervision, meaning the physician has to be in the exam room.

Example: Most pulmonary function tests require only general supervision, including the six-minute walk test (94620), says Alan L. Plummer, MD, professor of medicine in the division of pulmonary, allergy, and critical care at Emory University School of Medicine in Atlanta. Tests requiring direct supervision (the physician is in the office suite at the time of service) include pulmonary function tests requiring the administration of a bronchodilator (94060 and 94070), the use of low oxygen mixtures (94452 and 94553), or complex exercise (94621), he adds.

Be sure that you do not delegate the supervision of diagnostic testing to qualified NPPs, warns Carol Pohlig, BSN, RN, CPC, ASC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. Although the NPPs' state scope of practice may permit them to supervise such testing, the Medicare supervisory rules for diagnostic testing require an MD or DO to perform this function.

With increased scrutiny on incident-to services, it's important to document accurately and discontinue any "inappropriate flexibility" you may have taken advantage of in the past, advises Quinten A. Buechner, MS, MDiv, CPC, ACS-P/GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

Bottom line: Don't report your licensed NPP's services (nurse practitioners, physician assistants, etc.)  under the physician's identification number unless you'reconfident that you're reporting incident-to properly. You'll collect 15 percent less of the service's reimbursement by reporting under the NPP's own national provider identifier (NPI), but you'll be reporting properly.

Note: You must report the services of non-licensed NPPs, such as medical assistants, nurses, etc., as incidentto since these employees cannot be credentialed with their own NPIs.

To read the OIG's report on incident-to reporting, visit www.oig.hhs.gov/oei/reports/oei-09-06-00430.pdf.