Urology Coding Alert

How to turn 'incident-to' services from confusing to profitable.

Coding incorrectly for nonphysician practitioner services will cost your practice money - and maybe even attract federal fraud fighters - so your only chance to earn your fair share of reimbursement and to stay out of trouble is to know the "incident-to" rules backwards and forwards.
 
Practices can bill NPP services either as incident-to a physician or under the NPP's own provider number, so practices need to decide which method works best for them. Too many practices reduce this to a simple economic equation. They see that incident-to services are reimbursed at 100 percent of the Physician Fee Schedule and that NPP services get 85 percent. But there's more to it than simple math, experts warn - an incident-to coding misstep is likely to summon auditors to your door.
 
Noting that practices are billing incident-to with increasing frequency, the HHS Office of Inspector General continues to keep nonphysician practitioner services at the top of its watch list.
 
"The biggest problem with incident-to billing is that people aren't aware of the documentation requirement for the supervision component," says Carol Pohlig, BSN, RN, CPC, reimbursement analyst for the University of Pennsylvania. To bill a service incident-to, you need physician supervision from somewhere in the office space. To document this, Pohlig says, you need at least a simple phrase in the progress notes such as "Performed under the supervision of Dr. X" or "Service provided under supervision of Dr. X." It's a relatively simple thing to do, but "a lot of people fail to do that," Pohlig says.

New Patients and New Problems Aren't 'Incidental'

New patients - and, more important, established patients with new problems - can throw another monkey wrench into the incident-to machine. To bill NPP services incident-to a physician, you must provide the services to an established patient with an established plan of care. If an NPP sees a patient for any other reason, the service must be billed under the NPP's provider number.
 
When practices are especially busy, an NPP will see patient after patient and will bill incident-to the physician because these are patients who have been seen before by the doctor - either today or in the past for the same problem that they're in for today.
 
That's fine, says Emily Hill, PA-C, president of Hill & Associates in Wilmington, N.C. But practices run into trouble when the NPP sees a new patient or a patient who is presenting with a new problem for which he has not seen a physician. When this happens, the NPP can treat the patient but must bill under his own provider number. He cannot bill incident-to the physician for new patients or for old patients with new problems.
 
The coder needs to make clear when the NPP is seeing a patient incident-to the physician and when he's seeing a patient under his own provider number.
 
Play by the Rules - Win the Game

Medicare has four incident-to guidelines:

1.  Medicare defines incident-to services as being an integral, although incidental, part of the physician's professional service. "This makes it clear that the doctor must be involved in the patient's care," says Michael Powe, director of health systems and reimbursement policy for the American Academy of Physician Assistants (AAPA). "The physician must personally treat, diagnose and develop a treatment plan on the patient's first visit to the practice for a particular medical problem. Subsequent care and services can then be delegated, and billed, incident-to."
 
The supervising physician must also personally treat and diagnose established patients who are being seen for a new problem or condition. Be aware that services by a NPP must be billed under his or her name and personal identification number (PIN) if the NPP does not meet all of the incident-to billing requirements. Medicare covers these services at 85 percent of the physician rate.
 
2.  Incident-to services may be provided only in the physician's office, patient's home or an institutional office setting. The term "institutional office setting" describes a location where a physician leases a portion of another institution - such as a room in a hospital - as temporary office space. When an NPP provides care in such a space, you may report it as incident-to.
 
The 2002 CMS changes now permit billing incident-to for hospital visits, such as 99231-99233 (Subsequent hospital care). CMS Transmittal 1775 states that "when a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician
provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's unique personal identification number (UPIN)/personal identification number (PIN)." But if no face-to-face contact occurs between the doctor and the patient, even if the physician reviews the records, you should bill the service under the NPP's UPIN/PIN.
 
As a result of the change, your physician assistant (PA), as well as any other NPPs employed by the practice, can now bill an E/M for the morning rounds, if the urologist also visits the patient later that day. Incident-to rules, however, require the physician to initiate the plan of care.
 
This concept, while applicable to incident-to, is not applicable to "split billing" in a hospital setting, and you may want to omit this because it might make folks think that to use "split billing" you must follow the incident-to requirements, which is not the case (except that according to CMS you cannot "split bill" for consultations: You must bill using either the physician's number or the NPP's number, without combining the documentation and work.  For consults, the documentation and work done by the NPP cannot be combined with that of the physician and billed to the physician's number). 
 
3.  When delivering incident-to services, the NPP must work under the physician's direct supervision. "This does not mean that the doctor must be in the same room with the NPP," Powe says, "but it does mean that the physician must be physically present in the suite of offices."
 
Some doctors may have offices that connect with a hospital. They may simply walk through a door or hallway to get from one to the other. But if the physician crosses that boundary into the hospital, he can no longer be involved with the patient's care, according to Medicare rules. Services rendered in their office area at that point cannot be billed as incident-to. Similarly, a physician's availability by phone does not provide sufficient involvement.
 
4.  The physician and NPP must share a common employer in order to bill incident-to. The physician and the NPP must be employed by the same practice or, if the physician owns the practice, the NPP must be an employee of that practice.
 
If the practice employs NPPs as independent contractors, the services delivered by the NPPs can't be billed incident-to. HCFA provides one exception to this rule for PAs, who are permitted to form independent groups, subcontract their services to multiple practices, and bill incident-to.

Survive Audits With Solid Documentation
 
Some reimbursement experts estimate that fewer than 25 percent of incident-to claims filed are in full compliance. Experts also recommend that physicians sign NPP charts to document their presence while patients are still in the office. For their part, coders must ensure that the chart indicates the doctor's initial involvement in the patient's care and the development of a treatment plan.