Part B Insider (Multispecialty) Coding Alert

Published on Tue May 10, 2011 PDF

Follow these tips to ensure you're reporting incident to properly.

As most Part B practices are aware, under incident-to rules, qualified nonphysician practitioners (NPPs) can treat certain patients and still bill the visit under the doctor's National Provider Identifier (NPI), bringing in 100 percent of the assigned fee. But nailing down the complex incident to regulations can sometimes trip up even the most seasoned coder. Bill your incident to services properly every tie with this expert advice.

How it works: When an NPP provides a service to a Medicare patient incident-to the physician, you can report the service under the physician's national provider identifier (NPI) as long as all of the Medicare rules for incident-to services are followed. Doing so will net 100 percent pay for the service. When you bill for the NPP's service under the NPP's own NPI, however, you'll receive 85 percent of the full rate.

Be on the lookout for incident-to billing opportunities and ensure you're up to speed on the rules, or you could beshorting your practice on deserved reimbursement.

Ensure NPP Follows Provider's Action Plan

You can bill incident to the physician only when the NPP treats an established Medicare patient with a plan of care (POC) in place. The POC must also be the reason for the encounter. If the NPP addresses a new problem during the visit or if the physician has not previously established a care plan for the patient, then you cannot bill as incident to.

To qualify for incident-to billing, the physician must see the patient during an initial visit and establish a clear POC. If a patient comes in with a new problem, the NPP can see the patient, but must bill under her own NPI -- and you'll only receive 85 percent of the service's fee.

The physician should document in the POC that the patient will follow up with the NPP for monitoring of that particular encounter. Qualifying care could be for hypertension, diabetes, cancer, or other medical conditions. When there is a new problem, however, the physician must see the patient and modify the plan of care before the NPP can provide follow-up care and bill the services as incident-to the physician.

Verify Physician Supervision During Encounter

Your first step in collecting for incident-to services is determining whether the NPP was under direct supervision of a physician -- a Medicare rule you must follow to bill incident-to. The doctor must be readily available, which means that he or she should be in the office suite area.

Example: The NPP provides a level-three E/M service to an established Medicare patient with a plan of care (POC) in place for his hypertension. The visit is a checkupto see how the patient is responding to medication, diet, and other parts of the treatment plan, as well as how she might fare with other options. During the encounter, the physician is in his office down the hall seeing other patients. This visit should qualify as incident to.

Payment key: Since the encounter meets the supervision and POC requirements, you can garner 100 percent pay for this E/M service. Report 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) with 401.0 (Essential hypertension, malignant) appended under the physician's NPI.

Note: The supervising physician under which incidentto care is billed is not necessarily the physician who established the POC. Always bill incident-to services under the supervising physician, even if he is not the physician who wrote the POC.

Example: An NP is treating a patient's thyroid problem, following a plan of care laid out by doctor A. The supervising physician, however, is doctor B, and doctor A is out of the office. You can still bill the visit incident to, using doctor B's NPI since he supervised the encounter.

Be Sure NPPs Meet Incident-to Credentials

You should bill incident to only for NPPs who have the credentials to perform the appropriate services. The NPP could be a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) - as long as the NPP meets state and federal guidelines to report incident to. The NPP must be "licensed by the state under various programs to assist or act in the place of the physician," according to the Medicare Benefit Policy Manual, Chapter 15.