Part B Insider (Multispecialty) Coding Alert

Published on Thu May 22, 2003 PDF

How far away from a physician can nonphysician practitioners stray before incident-to billing goes away?

The answer may differ by state. But in general, the physician must be on the same premises as NPPs to bill for their services on an incident-to basis. This doesn't necessarily mean in the same room, says attorney Alice Gosfield with Alice Gosfield & Associates in Philadelphia. Any physician in your group can perform this supervisory role, she adds.

"For services to be billed incident-to, the physician must be in the clinic or suite immediately available to the NPP should a problem arise," stresses consultant Terry Fletcher with MedLearn Inc. in Laguna Beach, Calif. You can't bill incident-to for initial visits or services where the physician isn't in the clinic.

NPPs can bill under their own provider numbers at 85 percent of the allowable fee, with fewer requirements than incident-to billing, Gosfield says. Some NPPs can bill for the highest level of E/M visits either directly or incident-to, but they must have the proper state licenses, and state law must allow them to provide those services.

Physicians often overlook state law when deciding which services an NPP can provide, experts say. Even if an NPP meets all national requirements for incident-to billing, he or she may not be able to perform a service if state law doesn't allow it, and each state has different requirements.

Fletcher suggests asking your local Medicare carrier which services NPPs can provide in your state, because carriers keep careful track of this issue.

You can also contact the state branches of your professional association or your nurse practitioner's national associations, Gosfield says.

The most important thing to remember is that RNs can never bill for services over CPT 99211 , the level-one established patient visit, Fletcher says.