Oncology & Hematology Coding Alert

Incident-to billing may very well be your oncology practice's reimbursement nightmare before Christmas. If you have a carrier that has been imposing unfair interpretations of the rules or if your practice is fuzzy on the concept, recent clarification from CMS may expand your practice's opportunities. CMS may be trying to clear up issues resulting from complaints that some carriers are setting arbitrary interpretations of the incident-to rules, says Susan Callaway Stradley, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C. She has heard carriers argue that if a nonphysician practitioner (NPP) sees the patient, regardless of what is done and/or documented by the physician, the service must be billed under the NPP's provider identification number (PIN). That's simply not the case. While the incident-to rules remain substantially the same, clear-cut scenarios for applying them in office/clinic settings and hospital inpatient, outpatient and ED settings are now inscribed in the Medicare Carriers Manual. It's Splitsville for Shared Services Transmittal 1776 (Oct. 25, 2002) clarifies the MCM on the split-billing issue. It dictates that in the office or clinic setting, an E/M service that is split or shared between a physician and a nonphysician practitioner will be considered "incident-to" if the requirements for incident-to are met (see Fed. Reg. SS 2050.1, 2050.2 and 15505 subsection G) and the patient is an established patient. Oncology billers especially must never lose sight of the "established patient" requirement because an established patient with a new problem a scenario not uncommon during chemotherapy is treated like a new patient under incident-to billing, says Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett. "Established patient" still means an established patient with an established problem.

For example, if an NPP or a PA performs a portion of an E/M encounter and the oncologist completes the service, then the service should be reported under the doctor's PIN. If the incident-to requirements are not met because, for instance, the oncologist was called away on an emergency while the patient was in the office, the service must be reported using the NPP's PIN. In other settings, including hospital inpatient and outpatient settings, an E/M service shared between a physician and an NPP from the same group practice may be billed under either the doctor's or the NPP's PIN as long as the doctor provided some face-to-face portion of service. Consider this example: An NPP sees a hospital inpatient in the morning, and the oncologist sees the same patient face-to-face in the afternoon. In this case, the doctor or the NPP may report the service. However, if the doctor reviews an outpatient's medical chart without seeing the patient, the NPP must bill the service [...]