A New Way to Audit Incident-to Services
- By Lori Cox
- In Audit
- September 1, 2023
- No Comments
Proper documentation and accurate billing are essential aspects of healthcare compliance.
The Centers for Medicare & Medicaid Services (CMS) sets guidelines and regulations to ensure adherence to reimbursement rules for incident-to services. Some of CMS’ rules center around practices that employ advanced practice providers (APPs). When auditing medical records, it’s crucial to understand and apply CMS’ incident-to rules. This article aims to provide guidance on auditing medical records to ensure compliance with those rules.
Circumstances for Billing APP Services Incident-to
CMS’ incident-to requirements dictate the circumstances under which services provided by APPs can be billed under a supervising physician’s National Provider Identifier (NPI). To comply with CMS guidelines, the following key elements must be met.
APP Qualifications
APPs must be qualified healthcare professionals, such as nurse practitioners (NPs), physician assistants (PAs), or clinical nurse specialists (CNSs), and must work under the direct supervision of a physician. This means the physician must be physically present in the office suite and available to assist, even if they are not physically present in the same room during the service.
One exception to the supervision requirement is when certain behavioral health services are performed. The 2023 Medicare Physician Fee Schedule (MPFS) final rule allows general supervision for these. Under general supervision, the supervising physician does not need to be physically present while the service is being performed by the APP. However, the physician must be available for consultation or assistance if needed. The physician’s involvement may include providing general instructions or guidelines to the APP regarding the patient’s care, being available for questions or consultation, and periodically reviewing the services provided.
There are other exceptions as well, such as during the public health emergency (PHE) for COVID-19. CMS temporarily modified the regulatory definition of direct supervision, which requires the supervising physician to be “immediately available” to furnish assistance and direction during the service, to include “virtual presence” of the supervising clinician through the use of real-time audio and video technology. This flexibility is currently set to return to pre-PHE rules on Dec. 31, 2023.
Keep in mind that each state may have different rules, commonly known as the “scope of practice,” that indicate which services APPs can perform either under direct or general supervision.
Established Plan of Care
The APP’s services must be consistent with an established plan of care, initiated by the physician during a face-to-face encounter with the patient.
Take Steps to Compliance
When conducting an audit of medical records to assess compliance with CMS’ incident-to requirements, consider the following steps:
Review documentation of supervision: Ensure that the medical records clearly indicate the presence and availability of the supervising physician during the service. Look for evidence of collaboration, communication, and consultation between the APP and the supervising physician. If possible, look at the physician’s appointment schedule for that day to see if they were in the office seeing patients.
Assess plan of care documentation: Examine the medical records for documentation of an established plan of care by the supervising physician. Look for evidence of a face-to-face encounter with the patient, during which the physician initiates and documents the plan of care that includes services to be provided by the APP. Then make sure that the physician has been actively engaged in the treatment. The physician cannot just initiate treatment and allow the APP to treat the patient independently.
In addition, no new problems can be addressed if the service is going to be billed under the physician. The APP can only follow the treatment plan given by the physician. If the patient does have a new problem that needs addressed, the physician will either need to see the patient and treat the problem or the service will need to be billed under the APP.
Check billing and coding accuracy: Verify that the services rendered by the APP, billed under the supervising physician’s NPI, are appropriately coded using CMS’ billing guidelines. Ensure accurate documentation of the place of service, modifiers, and any other relevant billing requirements. Incident-to services are only allowed for office visits in the physician’s office and in the outpatient clinical setting. In the inpatient, observation, and skilled nursing home setting, the split/shared rules are used instead.
As you can see, an incident-to audit requires reviewing more than just one date of service. An auditor should have access to the electronic medical record system to review the entire chart, as well as appointment and vacation schedules.
Address audit findings: If any deficiencies or non-compliance issues are identified during the audit, it’s important to take appropriate action. This may involve implementing corrective measures, providing additional training to the healthcare providers, or developing policies and procedures to ensure future compliance. Document the audit findings, actions taken, and any follow-up steps to demonstrate due diligence.
If major issues are found, consider billing the claim directly under the APP rather than using the incident-to guidelines. We have many clients that do this because the guidelines do have some loopholes and are hard to track. Another benefit to billing under the APP is that when the patient gets the bill, you won’t receive phone calls wondering why they got a charge for a physician they did not see. Remember, though, that this will subject you to the 85 percent payment reduction: APPs are paid at a lower rate per CMS (and many payers).
Maintain Regulatory Compliance
Auditing medical records for compliance with CMS’ incident-to requirements is vital to maintain regulatory compliance, accurate billing, and proper reimbursement. By understanding the key components of CMS’ incident-to guidelines and following a systematic auditing process, healthcare organizations can ensure adherence to regulations and optimize patient care. Compliance with CMS’ incident-to requirements promotes transparency, reduces the risk of improper billing, and enhances overall quality of care in the healthcare industry.
Resources:
Powe, M., “What Pas Should Know About the 2023 Physician Fee Schedule Rule,” AAPA, Nov. 10, 2022
CMS, “Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19,” June 26, 2023
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