ED Coding and Reimbursement Alert

Question: The ED physicians want me to charge for overseeing endotracheal and nasogastric tube placements in the ED, although the respiratory therapists are the ones who performed the service.  Can we charge if the doctors don't actually place the tubes?

Wyoming Subscriber

Answer: Since the CMS "incident-to" provisions do not apply in the emergency department, the physician may not charge for a procedure that other hospital personnel performed on Medicare patients.

Here's how it works: Medicare has a concept called "incident-to" that allows a physician to bill for services provided by a nurse or other assistant. All of the services are billed as if the physician furnished them himself. To qualify, the service must meet several requirements:

 an "integral" part of a doctor's diagnosis or treatment

 provided under the "direct supervision" of a physician

 something ordinarily done in a doctor's office or clinic

 performed by an employee of that doctor. Incident-to sounds like a great concept, but unfortunately it is not applicable in the ED. Among other reasons, there are very strict employment criteria you must meet in order for the support staff performing the service to qualify. 

According to the Medicare Carriers Manual, Section 2050: "For hospital patients, there is no Medicare coverage of the services of physician-employed auxiliary personnel. ... Such services can be covered only under the hospital outpatient or inpatient benefit, and payment for such services can be made to only the hospital by a Medicare intermediary."

And most ED group arrangements run afoul of the employment requirements. Medicare states that in order to satisfy the employment requirements, the nonphysician must be an employee of the supervising physician as defined under the common law test of an employer/employee relationship. Most ED situations do not meet this requirement. The Medicare Carriers Manual further states, "Services provided by auxiliary personnel not in the employ of the physician ... even if provided on the physician's order ... are not covered as incident-to a physician's service." 

The incidental service must represent a direct expense to the physician, which usually disqualifies services provided by ancillary hospital personnel.