Common Billing Compliance Pitfalls

Common Billing Compliance Pitfalls

Part 1: Bolster the areas where your incident-to and shared billing falls short.

There are several major issues facing compliance officers today, such as HIPAA, Stark Law, and Anti-kickback Statute issues, as well as many billing compliance issues. Billing issues continue to appear in federal government False Claims Act settlement agreements and government audit reports. This month, we’ll discuss incident-to and shared billing compliance pitfalls and focus on what you can do to fix problem areas.

Incident-to Billing Rules

With the passing of the Balanced Budget Act of 1997, nurse practitioners and clinical nurse specialists in all geographic locations are permitted to bill Medicare directly. Physician assistants, however, still must bill their services through their employer. Certain qualified non-physician practitioners (NPPs) are permitted to provide services to Medicare patients, as long as the services are within their state-defined scope of practice. In addition, NPPs may bill for their services under their National Provider Identifier (NPI), or under a physician’s NPI if incident-to or shared billing requirements are met.

Evaluation and Management – CEMC

To bill incident-to a physician, the physician must first see and evaluate the patient and establish a treatment plan for the problem(s). Subsequent interactions for the same problem(s) may be billed incident-to the physician, as long as the employed NPP follows the course of treatment established by the physician and the physician is in the office suite when the NPP sees the patient. When NPPs make decisions to provide additional treatment for established problems or to treat new problems, these services cannot be billed incident-to the physician.

Example

A patient has osteoarthritis in both knees. The patient was evaluated by the physician, placed on a nonsteroidal anti-inflammatory drug, and advised to start a home exercise regimen and to return to the clinic in three months. The patient returns in three months, and is seen by the NPP for the arthritis. The patient complains that the knee pain is getting worse, so the NPP decides to administer corticosteroids into both knee joints (20610 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance). The physician is in the clinic, but does not order the joint injections. Nor does the physician adjust the previous treatment plan. Although the evaluation and management (E/M) service can be billed incident-to the physician because the problem is established and the physician requested that the patient return to the clinic, the joint injections may not be billed incident-to the physician because the physician did not order them or prescribe the joint injections in the treatment plan that was established when the patient first presented.

An NPP cannot refer to a patient as “theirs” — meaning the patient has always been seen by the NPP and has never been seen by a physician — if services are to be billed incident-to a physician.

Incident-to billing rules also require the physician to perform subsequent services at a frequency that reflects their active participation in, and management of, the course of treatment. Medicare does not define exactly how often this must occur. It’s a good idea for your organization to develop an internal policy that stipulates an annual, minimal requirement to demonstrate physician participation.

Lastly, applying the incident-to billing rules to services having their own statutory category under Medicare may end up short-changing a practice, or placing the practice at risk.

Example

A new patient presents to the clinic with labored breathing. The patient reports a history of asthma. The NPP sees the patient and bills an E/M service. The NPP also orders a bronchodilation responsiveness study (94060 Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration). A nurse performs the technical part of the study, and the NPP interprets the study. The services are billed under the NPP’s provider number because the patient is new and the physician is not in the clinic. The physician is not in the clinic to supervise the bronchodilation study, either. (Bronchodilation responsiveness studies are diagnostic tests and require direct physician supervision of the technical component.) NPPs are not permitted to supervise the technical component of a diagnostic test, so this piece of the study cannot be billed. As a diagnostic test, the bronchodilation responsiveness study is exempt from the incident-to billing rules. If the NPP had personally performed both the technical component and professional component of the study, it would have been appropriate for the NPP to bill this is as a global service under the NPP’s provider number.

Incident-to Billing Concerns

Be sure your practice’s billing software has features to identify services performed by NPPs that are billed incident-to a physician.

Example

Where I work, the NPP performing the service is entered into a documenting provider field, while the physician’s name is entered into the billing provider field. When billing reports are run, we make sure these two fields are included. This enables us to differentiate between physician services billed under the physician’s provider number and services performed by NPPs billed incident-to a physician. This also helps us to track NPP productivity.

Without the ability to run reports and determine which services were billed incident-to a physician, you may find that, from an auditing perspective, you will have to review many more samples, and your audit universe may be much bigger than it needs to be. A bigger audit universe creates a bigger financial risk if problems are found in a probe sample.

Billers, coders, and providers must not assume that if it’s an established problem, it’s OK to bill everything incident-to the physician. You must look at all of the services provided to determine which falls within the plan of treatment established by the physician, or whether the incident-to guidelines even apply.

Shared Billing Rule

Major areas where shared visit documentation falls short are the physician’s documentation of a face-to-face encounter, and the provision and documentation of a substantive part of an E/M service.

A substantive portion of an E/M visit involves all or some portion of the history, exam, or medical decision-making (MDM) components of an E/M service. A “teaching physician-type” note, which indicates the physician saw and examined the patient and agrees with the NPP’s assessment and plan, is not sufficient. The physician must document that they performed a face-to-face service with the patient, and must document a substantive portion of one of the key components of an E/M service.

In a hospital-based setting, an E/M visit performed by an NPP and physician may be shared (assuming it is properly documented), but if a bedside procedure is performed by the NPP, it must be billed under the NPP’s provider number because the shared billing rules apply only to E/M services, not procedures. The NPP also must be employed by the physician practice.

An E/M visit between a hospital-employed NPP and a physician cannot be billed under the physician’s provider number because the NPP is not in the same group practice as the physician. Services performed by the hospital-employed NPP do not create a billable expense for the physician practice. Understand who employs the NPP and whether there are any lease agreements in place between the hospital and the physician practice for the use of the NPP. Shared billing rules apply to NPPs and physicians in the same group practice, so NPPs and physicians working for large health systems with multiple group numbers need to be careful when billing. This may be more prevalent in facilities with cross-clinical units such as neuro-intensive care units.

Example

An NPP is a member of the neurology department and is enrolled in and bills services under the neurology group number. The physician is a surgical intensivist, but bills and is enrolled under the surgery group number. Because the NPP and the physician are not in the same group practice, an E/M encounter shared by these individuals could not be billed as a physician service unless the physician’s documentation independently meets all of the requirements for billing an E/M service. Remember: Medicare Part B does not pay for NPP services rendered incident-to a physician in a hospital.

Although the Medicare Claims Processing Manual clearly states that critical care cannot be billed as a shared service, it’s best to check with your local Medicare administrative contractor about other time-based services. Local policies vary on whether a hospital discharge service (a time-based code) may be billed as a shared visit.

Manage the Nuances of
Incident-to and Shared Billing 

Both the incident-to guidelines and shared billing rules can be difficult to manage, and can increase compliance risk for a practice unless you have a firm handle on the nuances. Some practices have determined it’s financially prudent to stop billing incident-to for services because the billing hassles or compliance risks outweigh the 15 percent difference in Medicare reimbursement.

Before giving up the 15 percent payment, consider developing a decision chart as a tool for your NPPs and billing staff. The tool will help them to determine under which provider they should bill a shared billing or incident-to service. Depending on the practice, you could create one chart for the office setting and another for hospital-based settings, and list common scenarios that the NPPs would encounter. Be sure to include the level of physician supervision necessary to satisfy both federal billing requirements and state scope of practice requirements.

See Table A (on the preceding page) for examples of what to include in a decision chart for an office-based practice.

Table A

Type of Encounter Scenario Medicare Florida Medicaid
New Patient Patient is not seen by any physician in office, yet. Bill under the ARNP/PA’s NPI.

Physician must be available at least via phone.

Bill under the physician’s NPI.

Physician must be in the building.

Physician must sign and date the medical record within 24 hours.

OR

Bill under the ARNP/PA’s NPI.

Physician must be available at least via phone.

Established Patient New Problem

Physician has not treated patient for this problem.

Bill under ARNP/PA NPI

Physician must be available at least via phone.

Bill under the physician’s NPI.

Physician must be in the building.

Physician must sign and date the medical record within 24 hours.

OR

Bill under the ARNP/PA’s NPI.

Physician must be available at least via phone.

Resource

Medicare Benefit Policy Manual, Publication 100-02, Chapter 15 – Covered Medical and Other Health Services, section 60.1 (B)

 

Maryann Palmeter

Maryann Palmeter

Maryann has over 30 years of experience in the healthcare industry with emphasis on federal and state government payer billing and compliance regulations. She is employed with the University of Florida Jacksonville Healthcare, Inc. as the director of physician billing compliance where she provides professional direction and oversight to the Billing Compliance Program of the University of Florida College of Medicine – Jacksonville. Maryann served on the AAPC's 2011-2013 National Advisory Board and the 2013-2015 Board as secretary. Palmeter currently serves the Jacksonville, Florida local chapter as education officer and has served as president, president-elect, and member development officer. Palmeter was named the AAPC’s 2010 “Member of the Year.”
Maryann Palmeter

About Has 16 Posts

Maryann has over 30 years of experience in the healthcare industry with emphasis on federal and state government payer billing and compliance regulations. She is employed with the University of Florida Jacksonville Healthcare, Inc. as the director of physician billing compliance where she provides professional direction and oversight to the Billing Compliance Program of the University of Florida College of Medicine – Jacksonville. Maryann served on the AAPC's 2011-2013 National Advisory Board and the 2013-2015 Board as secretary. Palmeter currently serves the Jacksonville, Florida local chapter as education officer and has served as president, president-elect, and member development officer. Palmeter was named the AAPC’s 2010 “Member of the Year.”

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