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Urology Coding Alert

Recognize Incident-To Services or Pay the 15-Percent Price

Published on Tue Jan 13, 2009

Knowing the rules determines 100 percent vs. 85 percent reimbursement.

In the office setting, incident-to billing is an essential gear in a urology practice's reimbursement machine. Each time a nonphysician practitioner (NPP) provides services or treatment to a Medicare patient, you should be on the lookout for the opportunity to code the service incident-to the physician.

Why? Under incident-to rules, qualified NPPs can treat certain patients and still bill the visit under the urologist's National Provider Identifier (NPI), bringing in 100 percent of the assigned fee for the codes you report.

But if you aren't following the stringent incident-to billing rules, you're only setting your practice up for lost reimbursement and possible fraud charges. Make sure you're capturing every dollar your NPPs deserve with these expert tips.

1. NPP Has to Follow Established Plan of Care

To qualify for incident-to billing, the urologist must see the patient during an initial visit and establish a clear plan of care, reported Sharlene Scott, CPC, CPC-H,CCS-P, CCP-P, PMCC, during a presentation at The Coding Institute's multispecialty conference in Orlando,Fla. (www.codinginstitute.com).

If the NPP is treating a new problem for the patient, or if the urologist has not previously established a care planfor the patient, then you cannot report the visit incident-to.

Beware: An established patient with a plan of care who comes in for a new, unrelated condition is not an appropriate case to bill incident-to. For Medicare you cannot bill new patient visits, consultations, or services provided in the hospital as incident-to services.

Tip: The physician should document in his plan of care that the patient will follow up with the NPP for monitoring of that particular episode of care. That care could be for managing a urinary infection, symptomatic prostatic enlargement, urinary incontinence, or other urological or medical conditions. When there is a new problem, however, the physician must see the patient and modify the plan of care before the NPP can provide any follow-up care and bill the services as incident-to the physician.

2. Physician Presence Is Essential

Your first step in collecting for your practice's incident-to services is determining whether the services involved "direct" supervision. This means that the urologist must be in the immediate office suite while the NPP is performing the incident-to services.

Key: You should not use the term "direct" too loosely.Having the 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 to check your state's practice requirements to see if your state has different supervision requirements.

"The physician must be present in the office suite in order to bill as incident-to," says Nicole Martin, CPC,owner of Innovative Coding Analysis in Coplay, Penn. "He does not have to be in the treatment room itself but in the office [suite]."

Example: A nurse practitioner in your office performs the physical exam for a patient, and the urologist calls in and does the history portion of the exam. The physician wants to bill this service incident-to.

In this scenario, "the service would be billed directly under the NP's own provider number and reimbursed at the 85-percent level," Martin says. You cannot bill this service incident-to because the urologist was not providing direct supervision.

Good idea: Retain physicians' work schedules on file to prove they were present when incident-to services occurred. Keep in mind that some payers like to see the name of the supervising physician in the progress notes -- especially if it is a different physician than the one who wrote the plan of care.

Remember: As of November 2004, the supervising physician can be different from the one who actually wrote the plan of care. The reimbursement must go to the physician who supervised the incident-to services on the day that the services were provided, however.

As long as a patient is an established patient with a predetermined plan of care, a nurse practitioner can submit a claim incident-to a supervising physician, even if that physician did not establish the initial evaluation and treatment plan. For accuracy and proper documentation,you need to record the initial evaluating physician's name and NPI in boxes 17 and 17A of the CMS 1500 form when another physician provides the supervision for subsequent office care.

3. Don't Forego Pay If Physician Isn't Around

If the NPP service doesn't fit incident-to regulations,that doesn't mean you have to forego payment altogether.If you do not bill an NPP visit incident-to the physician,then you should code the service under the NPP's NPI number. Expect Medicare to reimburse you at 85 percent of the global, or full, fee.

Example: A PA sees an established patient with Medicare coverage, but none of the physicians are in the office at the time. This is not an incident-to billing situation under Medicare guidelines.

Instead: "You can bill for a PA's time, just not under any of the doctors'," says Samantha Daily, medical biller for Urologic Consultants PC in Portland, Ore. "You have to bill under the PA's name."

"PAs may bill under their own NPI," Martin agrees."This would also depend on the payer. Some payers do not recognize mid-level providers. You can also confirm this by visiting the American Academy of Physician Assistants Web site" at www.aapa.org/gandp/3rdparty.html.

As stated above, Medicare will reimburse 85 percent of the global fee for NPP services that do not meet incident-to rules. Private or commercial payers, especially if they do not recognize incident-to rules or do not credential NPPs, usually pay full physician fees for NPP services provided the physician is available for "general" supervision. This is irrespective of the urologist's presence in the office or whether the patient is established, new, or a consultation.

Note: There are some payers who do not recognize mid-level providers and will not reimburse for their services at all. Be sure you check with each payer to determine which rules you should follow.

Important: If you spent hours poring over the 23- page incident-to guidelines that CMS had planned to implement on June 2, make sure you forget everything you learned, at least for now. On the very day that practices were supposed to start using the new incident-to guidelines, CMS rescinded Transmittal 87, noting that the document "will not be replaced at this time."

Possible rationale: Several medical associations expressed concern about the new guidelines, saying that practices didn't have enough time to learn all of the rules and nuances in the one-month period between the transmittal's publication (May 2) and the implementation date (June 2). So, for now, stick with the old rules. 

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