General Surgery Coding Alert

Keep Tabs on Surgeons Whereabouts to Avoid Incident-To Snafus

Published on Sat Mar 01, 2003

A surgeon's phone call is not enough to allow a surgery practice to bill "incident-to" services physicians must be on-site if they hope to reap the lucrative rewards of incident-to billing.

The U.S. Department of Health and Human Services Office of Inspector General's (OIG) 2003 Work Plan states that it intends to scrutinize "several potential" nonphysician practitioner (NPP) billing vulnerabilities in 2003. Consequently, general surgery practices need to ensure compliance now to avoid problems with potential payer and federal audits.

The Medicare Carriers Manual (MCM) specifies the following guidelines for billing incident-to services:

The physician must be on-site at the time of treatment.

The physician originally had a face-to-face encounter with the patient during his or her first visit to the office or clinic.

The physician sees the practice's established patients for any new medical problems or exacerbation of old problems that require a change in the plan of care.

Remember, for you to bill NPP services incident-to a physician, the services need to be provided to an established patient with an established plan of care. If an NPP sees a patient for any other reason, the service must be billed under the NPP's own provider identification number (PIN).

Document Surgeon's Supervision

NPPs, such as physician assistants (PA) and nurse practitioners (NP), may perform a variety of services under a surgeon's supervision, such as follow-up wound care, stoma care for ostomy patients and procedure-related instruction.

Failing to document supervision may lead to a Medicare or other payer audit. And although a surgeon may be able to show an auditor his schedule to prove that he was in the office at the time, this is still a time-consuming and therefore costly hassle that you could easily avoid with better documentation.

"The biggest problem with incident-to billing is that people aren't aware of the documentation requirement for the supervision component," says Carol Pohlig, BSN, RN, CPC, reimbursement analyst for the University of Pennsylvania.

To bill a service incident-to, you need physician supervision from somewhere in the office space, which means that the surgeon must be in the suite but need not be in the same room as the NPP when he or she is providing services.

To document this, Pohlig explains, you need at least simple phrase in the progress notes such as "service provided under supervision of Dr. X." It's a relatively simple thing to do, but "a lot of people fail to do that," Pohlig says.

Avoid Phone-In Advice

Sometimes incident-to guidelines aren't clear-cut in surgery practice settings.

For instance, an established patient with venous stasis ulcers (454.0) comes into the office for selective wound debridement (97601, Removal of devitalized tissue from wound[s]; selective debridement, without anesthesia [e.g., high-pressure waterjet, sharp selective debridement with scissors, scalpel and tweezers], including topical application[s], wound assessment, and instruction[s] for ongoing care, per session), but a PA discovers that the patient's blood pressure has risen significantly since her last visit.

The PA phones the surgeon, who is detained at the hospital, and the surgeon advises the PAto evaluate the patient and determine a cause of the high blood pressure (401.x-405.x). The practice bills the PAE/M evaluation (99211-99215, Established patient office visit ...) as incident-to, arguing that the surgeon supervised the PA and plans to dictate a note later for the patient's chart.

This is not correct incident-to coding, coding consultants warn. Not only was the physician off-site, which instantly disqualifies the evaluation from incident-to billing, but if the high blood pressure is a new problem, the physician would need to evaluate the patient and establish a plan of care before anyone else could bill the high blood pressure evaluation incident-to.

The PA should bill for the wound debridement and the E/M evaluation under his or her Medicare PIN. The claim submitted under the PA's number would read as follows:
97601 Diagnosis: 454.0 (Varicose veins of lower extremities, with ulcer)
99211 Diagnosis: 401.x-405.x (Hypertension)

Payer Requirements Aren't Incidental

Accurately reporting incident-to services means that general surgery coders need a clear understanding of Medicare's and private payer's incident-to guidelines.

To make the task a little more manageable, Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, a general surgery coding and reimbursement specialist and a coding instructor at Clarkson College in Omaha, Neb., offers the following reimbursement pointers:

Contact non-Medicare payers for their specific incident-to guidelines. Many payers have rules that are dramatically different from Medicare's requirements.

Services that can be billed incident-to include any that are within the scope of the midlevel (nonphysician) practitioners'state license.

Generally, NPP's provide incident-to services in physicians'offices, but some insurers will also allow incident-to billing in other locations. Be sure to check with individual insurers for those rules.

Many practices bill incident-to when the physician isn't in the office, get paid for it, and assume that it's OK to continue, coding consultants say. The carrier may have paid you, but you still did not code it correctly, and if the payer audits you, you're in noncompliance.

Note: For more information on the OIG's 2003 Work Plan, see http://oig.hhs.gov/publications/workplan.html.