Urology Coding Alert

Don't forget you can still get 85 percent reimbursement if you don't meet incident-to criteria.

As practices try to battle falling income, many are striving to maximize the urologists' time and supplement services using non-physician practitioners (NPPs). If you know the incident-to billing rules, you will ensure a 100 percent reimbursement for those services. But if you're not careful, you'll set yourself up for denials and potentially fraud accusations. Follow three expert tips to ensure your Medicare incident-to billing brings in extra reimbursement while still staying legal and compliant.

Watch Out for New Patients and New Problems

You can bill "incident to" only when the NPP treats an established Medicare patient who has been seen initially by the urologist who has established a particular plan of care (POC) for this individual patient. The POC must also be the reason for the encounter. If the NPP addresses a new problem during the visit or if the physician has not previously established a care plan for the patient, then you cannot bill the service as incident to.

Your urologist should also document in the POC that the patient will be followed by an NPP to monitor the response to the planned therapy. You might encounter this follow up visit by a NPP for urinary tract infections, incontinence, cancer diagnoses, or other medical conditions.

Watch out: When there is a new problem, however, the physician must see the patient first and modify the plan of care before the NPP can provide follow-up care and bill the services as incident-to the physician. For Medicare you cannot bill new patient visits, consultations, or services provided in the hospital, nursing home, or outpatient facility as incident-to services.

"If the desire is to bill the service under the MD and the patient is new, only the review of systems (ROS) and past, family, and social history (PFSH) portion of the encounter can be recorded by the NPP" says Suzan Berman, CPC, CEMC, CEDC, senior manager of coding education and documentation compliance with UPMC in Pittsburgh, Penn.. "The physician would need to reference this in his/her note."

Important: You also need to know your state's laws governing the scope of practice for your different NPPs, warns Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, MI. Medicare guidelines specify that "coverage is limited to the services a PA or NP is legally authorized to perform in accordance with state law," she adds.

Ensure Proper Supervision Before Billing

One of the first things you should check before you bill a service incident-to is whether a urologist or other physician was directly supervising the NPP. In other words, the provider whose national provider identifier (NPI) you'll be billing under should be supervising the service.

Define direct supervision: According to an MLN Matters article SE0441 (www.cms.gov/mlnmattersarticles/downloads/SE0441.pdf), in order to bill incident to the physician, the urologist does not "have to be physically present in the patient's treatment room while these services are provided, but you must provide direct supervision, that is, you must be present in the office suite to render assistance, if necessary."

Key: Do not use the term "direct" too loosely. Having the supervising physician available by phone or having the urologist somewhere on the grounds in a large facility is not acceptable by Medicare standards. Also, you may want tocheck your state's practice requirements to see if your state has different supervision requirements.

"Under Medicare's ruling, 'incident to' can only be met if the MD is in the office," Berman confirms. "If a mid-level provider (MLP) is in the office, the service could be billed 'incident to' him/her if the service is done by someone with a 'lesser' license. For example, an MLP can supervise an RN (registered nurse) or MA (medical assistant)."

Example: The nurse practitioner (NP) provides a level-three E/M service to an established Medicare patient with a plan of care (POC) in place for his symptomatic prostatic enlargement. The visit is a check-up to see how the patient is responding to medication, diet, and other parts of the treatment plan, as well as how he might fare with other options. During this encounter, the urologist is in the office suite seeing other patients. This encounter qualifies for incident-to billing under the urologist's NPI.

If, during the same encounter with the NP and the patient, the urologist was five miles away at the hospital seeing patients, you would not be able to bill that E/M service incident-to the urologist.

Tip: The supervising urologist does not need to be the physician who initiated the treatment plan, Berman says. You should bill in the name of the physician present in the office suite and providing the supervision at the time of the visit by the NPP, whether or not he initially saw the patient and developed the plan of care. "The billing must reflect this difference," Young says. " Physician supervising in the office goes in box 33. The physician who wrote the plan of care for the visit goes in 17."

Switch to NPP's NPI When Necessary

If you find the service does not meet incident-to billing requirements -- for example, if the NPP sees a new patient -- you don't have to forego payment altogether in many cases. If a Medicare credentialed NPP provides the service, you can bill under his own NPI. In that case, you'll usually receive between 65 and 85 percent of the normal global fee found in the Medicare Physician Fee Schedule, depending on the type of NPP, Young says.

Exception: If a member of your auxiliary staff, such as a medical assistant (MA), provides a service when there is no direct supervision, you cannot bill for the service.

Example: A patient comes into the office in painful urinary retention, and requires an immediate Foley catheter insertion to relieve the acute obstruction. Unfortunately, your urologist has the day off, and the covering PA is at the hospital seeing another patient. Your medical assistant who has been fully trained in catheter placements inserts the catheter after conferring with the PA on the phone.

"The MA should certainly provide the care in emergent case (as long as it is within their scope of practice)," Berman says. "It just wouldn't be billable" because there is no direct supervision by a physician.

Important: Different payers have different rules and some do not recognize Medicare's incident-to rules, so check with your private payers before billing NPP services.