Don’t Let Incident-to Turn into “Incident-4” Billing
When a registered nurse bills under the nurse practitioner, you are liable for overpayments.
By Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, CPMA
Q: I am reaching out in the hopes of receiving guidance to a question posed by one of my physicians. This particular physician works offsite from the office, usually in the hospital located on the same campus. This physician employs a staff member who is a certified urologic registered nurse (CURN). The CURN performs scheduled urodynamic studies in the office while the physician is working at the hospital. This same physician also employs a nurse practitioner (NP) who remains in the office while the doctor is offsite at the hospital.
Can the urodynamic studies performed by the CURN, bill incident-to (I2) under the NP? If the urodynamic studies are billable as incident-to under the NP, can the physician expect a 15 percent reduction in reimbursement?
I appreciate any direction or resources I can check that may assist in this area.
A: This is jokingly called “incident-4” billing. Jokes aside, it is not permissible.
There is no authority for billing a service performed under the direction of a nurse practitioner or other non-physician practitioner (NPP) such as a physician assistant (PA). NPs/PAs have no delegation authority under Medicare/Medicaid. It’s also important to understand that the I2 rule applies only with respect to services that are incidental/integral to a physician’s plan of care and which are performed under the direct on-premise supervision of a licensed and credentialed physician. It’s presumed from your question that the CURN cannot be credentialed by Medicare/Medicaid, which would permit her or him to bill the urodynamic studies under her or his own National Provider Identifier (NPI). Assuming this to be the case, the only way the urodynamic studies performed by the CURN could be billed legitimately is under the physician, provided the studies were performed in compliance with all elements of the I2 rule, as follows:
- The physician performed the initial evaluation of the
patient (not the NP) and ordered the test (thereby making the test an incidental, although integral, part of the physician’s service).
- The physician remained actively involved in the care.
- Both physician and CURN are employed by the same entity, or if they are not in a group, the physician employs the CURN.
- The CURN qualifies as auxiliary personnel under state licensure rules, which must permit the physician to delegate physical performance of the urodynamic study to the CURN.
- The physician provides direct on-premise supervision (i.e., in the office suite) during the performance of the test.
The primary issue based on your question is that the physician is not on premise when the study is performed. I also cannot tell whether the initial visit and order requirements of the I2 rule are satisfied. The I2 rule, again, does not permit the NP to supervise the performance of any service, even if permissible under their state licensure rules. Additionally, under the facts provided, because ALL of the above elements are not satisfied, and because the CURN performed the service, the service is not compensable. It would not be correctly reportable under either the NP or the physician. Remember: I2 does not apply to services ordered/supervised by a NPP, such as an NP or PA.
Bottom Line: Assuming the service was billed under the NP but not performed by the NP, it is not compensable and money paid for the service is an overpayment. Any overpayments should be refunded voluntarily to avoid potential False Claim Act liability for failure to refund an overpayment. The act provides 60 days from the date that specific overpayments are identified by anyone in the organization. The clock starts right now. If you need legal assistance with the overpayment disclosure, please don’t hesitate to contact me.
Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, CPMA is president elect of AAPC’s National Advisory Board, serves on the AAPC Legal Advisory Board, and is the AAPC Ethics Committee chair. He has over 20 years of experience in healthcare coding and over 16 years as a compliance expert, forensic coding expert, and consultant. He has provided expert analysis and testimony on coding and compliance issues in civil and criminal cases and his law practice concentrates on representing healthcare providers in post-payment audits and with responding to HIPAA OCR issues. He speaks on a national level, and is published in national publications on a variety of coding, compliance, and health law topics. He is a member and president of the Johnstown, Pa., local chapter.
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