Orthopedic Coding Alert

Established plan of care a must to bill under physician's NPI.

Orthopedic practices that are not taking advantage of Medicare's incident-to billing opportunities are missing out on a valuable revenue stream.

How? If an encounter meets all of the parameters for incident-to billing, you can report the service under the physician's national provider identifier (NPI), gaining full pay for the encounter. Without incident-to, you have to report the same service under the nonphysician practitioner's (NPP's) NPI, which pays out at 15 percent less than the physician's.

15 Percent Per Patient Can Add Up

The $kinny: Let's say that a qualified NPP provides a levelfour E/M service for a patient with . The visit meets all of the incident-to parameters, but you report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity ...) under the NPP's NPI instead of the physician's.

The average full payout for 99214 is about $100 (3.01 nonfacility relative value units [RVUs] multiplied by the 2011 Medicare conversion rate of 33.9764), so coding this visit incorrectly will cost your practice about $15. But you can pick up every dollar the practice is entitled to -- and stay compliant -- if you heed this incident-to advice.

Check for Established Care Plan

If the NPP is not following a clear plan of care set out by a physician in the practice, you cannot report a visit incident-to the physician, reports Sharlene Scott, CPC, CPC-H, CCS-P, CCP-P, PMCC, instructor with Coding Academy of America/American Coding Centers in Baltimore.

So if the NPP is treating a new problem for a new or established patient, or if the orthopedist has not established a care plan for the patient, then you cannot report the visit incident-to.

Example: An established Medicare patient reports to the orthopedist on Dec. 13, 2010, with a fracture in her left shoulder. The orthopedist performs an E/M service, diagnoses the patient with the fracture, performs closed treatment and writes prescriptions. On Jan. 4, the patient returns to the orthopedist for a follow-up visit. A qualified NPP checks the patient's vitals, asks her how her recovery is going and if she needs refills for any prescriptions.

In this example, you can report the NPP's service incident-to the physician. On the claim, report the appropriate level E/M code --" and don't forget to file the claim under the supervising physician's NPI rather than the NPP's NPI to ensure 100 percent pay for the service.

Remember: The NPP's visit can be reported incident-to the physician in this instance -- as long as the encounter meets supervision requirements and the NPP is qualified to provide the service.

Observe 'Direct Supervision' Rule

In order to bill incident-to the physician, the NPP must be working under "direct supervision" of a practice physician. "Direct supervision means the physician must be present in the office suite and immediately available throughout the time the service is being provided," explains Ruby O'Brochta-Woodward, BSN, ACS-OR, coding and research specialist at Twin Cities Orthopedics in St. Louis Park, Minn.

Medicare's definition of an NPP working under direct supervision "refers to the MD being present in the office suite and immediately available to render assistance if necessary. MDs do not have to be physically present in the exam room with the NPP," explains Ana Rosario, CPC, compliance auditor with Harvard Medical Faculty Group at Beth Israel Deaconess Medical Center.

Also: The supervising physician for the incident-to service does not need to be the physician that authored the plan of care, O'Brochta-Woodward says. "But the provider number [NPI] under which the service is billed must be that of the physician actually present when the service was performed," she continues.

Example: The NPP provides an E/M service for a patient with an established plan of care in place for club foot. Dr. X initiated the plan of care, but Dr. Y is the supervising physician during the visit.

In this scenario, "although you are following Dr. X's treatment plan, you would bill under Dr. Y as the supervising physician. CMS states in order to bill incident-to you must bill under the supervising physician's [NPP], which would be the physician who is present in the immediate office. CMS also states any physician members of the same group may be present in the office to supervise," explains Rosario.

Know Your NPP's Scope of Practice

Check with you payer before billing incident-to if you have any questions about whether or not a procedure/ NPP is eligible for incident-to; the rules for reporting these services can get slippery, especially in an orthopedist's office that could have several different"types" of NPP on staff.

Bottom line: Not all NPP's can provide all types of incident-to services in all states. It is important that you know just what services the NPP is qualified to provide, and what he should not perform.

NPP is a generic title for any provider who is not a physician, so incident-to billing "would be dependent upon the scope of practice for that provider in the state in which the service is being performed or provided," O'Brochta-Woodward says.

In a nutshell: Incident-to billing eligibility will depend on:

• What type of NPP provides the service
• The orthopedic practice's scope of practice
• State regulations for NPPs.
• For example, O'Brochta-Woodward offers just a few incident-to guidelines coders need to consider:
• only a physician, nurse practitioner (NP), physician assistant (PA) or certified nurse specialist (CNS) can order an x-ray
• PAs, NPs and CNS's can only order tests if they are allowed by their individual states
• Medicare's physical therapy (PT) rules state that only providers who have been trained in PT can bill for the service. "Therefore RNs, medical assistants, ortho technicians cannot perform PT services that would be billed incident-to the physician," O'Brochta-Woodward explains.

Best Bet: Include Authorizing Statement

To protect your incident-to claims, you might consider asking the physician to document a brief authorizing statement when authoring the patient's initial plan of care. For example, you might consider the following note:

"Established care plan for patient's fibula fracture. OK to see NPP for follow-up."

"This [step] is advisable, since in order to bill a service as incident-to, the supervising provider must show direct, personal involvement with initiating the course of the treatment," says O'Brochta-Woodward.

Evidence: Check out Medicare's Part B Policy PHYS004, which states that there must be evidence of continued "active participation in and management of the course of treatment" in order to bill incident-to the physician.