Wiki Mohs surgeon billing under the general dermatologist's NPI

[CatchTheWind]

I have always been under the impression that one doctor cannot bill under another doctor's NPI except under a true Locum Tenens situation. But a friend who works in another derm practice says that her doctor brings in a Mohs surgeon once a week and bills insurance under his own name for the Mohs surgeon's work. When my friend told him he is not allowed to do this, he replied that he has checked into this and found that it is permitted.

Is there something I don't know here, or is he committing fraud?

 

[Spring2Code]

Hi, unless something has changed the doctor who is billing better be performing the mohs surgery. Reference listed below from AAPC Knowledge Center. Hope this helps.

Step 1:
Confirm the Surgeon and Pathologist Are the Same

Mohs requires that a single physician act as both surgeon (excising tissue) and pathologist (immediately examining excised tissue to determine clear margins). Per CPT®, “if either of these responsibilities is delegated to another physician or qualified health care professional who reports the services separately, the … [Mohs] codes should not be reported.”

Full Article:
https://www.aapc.com/blog/27003-code-mohs-in-6-easy-steps/

 

[CatchTheWind]

Thanks!

That's not really the issue; the Mohs surgeon is performing the pathology, so the Mohs is being done properly as a "Mohs." The problem is that he is working in someone else's office, and the practice owner is billing under his own NPI rather than under the "visiting" Mohs surgeon's.

 

[ellzeycoding]

There may be problems with this. I see several red flags.

First, it is possible for one physician to provide incident-to services under another physician. Examples may be when a physician joins a group and is waiting to get credentialed. He is employed by the group, but hasn't been accepted by Medicare or the plans with the group. This new physician can see patients under a supervising physician and bill under the supervising physician's NPI number until they are credentialed.

Here is an AAPC article on this.

https://www.aapc.com/blog/26668-risks-abound-for-non-credentialed-physicians-using-incident-to-rule/


There are often other restrictions. Some commercials may require that the other physician (or mid-level provider) be added/listed under the main provider's contract and have additional or separate malpractice coverage.

For Medicare, there is usually an employment requirement that must be in place.

I would have a healthcare attorney review this practice and see if this type of "visiting Mohs surgeon" can meet the employment requirement for billing incident-to under another provider's NPI number. It may be possible.

Questions would remain if the Mohs surgeon is actually providing an incident-to service, since the main dermatologist isn't a Mohs surgeon and can't establish a plan of care for the Mohs surgeon to follow.

There is this 'service' I found online, so you can field the question with them, on how they get around the billing legalities.

https://www.gotmohs.com/

 

[CodingKing]

Direct Supervision might be the biggest issue, outside of plan of care. If the physician cannot do MOHS on their own and has to being in outside help, how can they be immediately available to furnish assistance anddirection throughout the performance of the procedure they aren't skilled to perform ?

 

[ellzeycoding]

Direct Supervision might be the biggest issue, outside of plan of care. If the physician cannot do MOHS on their own and has to being in outside help, how can they be immediately available to furnish assistance anddirection throughout the performance of the procedure they aren't skilled to perform ?

Mohs is just regular excision plus frozen section by the pathologist/surgeon. The regular derm can supervise and assist with the excision part without issue. But I don't think there is really a concern with the path part, as far as intervening in the event of problems.

 

[thomas7331]

But supervision is only one of the requirements that have to be met in an 'incident to' arrangement - another is that the provider billing 'incident to' cannot initiate or change the plan of care. I think it would be like walking a tightrope to have a physician performing a surgical procedure meet the 'incident to' requirements in a situation like that. The supervising physician would need to be involved in any decisions made for that patient in the course of the procedure, and would need to write the pre- and post-operative orders. I would think that would also mean they need to sign off on the diagnosis of the pathology and order the second layer excision, if required - the Mohs surgeon, if acting 'incident to', could not initiate that plan independently. I agree with CodingKing and think it would be very difficult to defend in an audit that a physician with the additional training in Mohs is acting completely 'incident to' a general dermatologist.

Except in the case of a locum, billing one physician's services under a different physician's credentials is, in my opinion, a risky proposition at best. Credentialing a physician with the payer is not that difficult and I don't understand why any practice wouldn't just do it and avoid putting themselves at risk. But agreed that this is the type of thing a practice lawyer or compliance specialist should review and sign off on - without being able to know all of the relevant details of that practice's arrangements we certainly aren't in position to pass final judgment on something like this on an internet discussion forum.