Part B Insider (Multispecialty) Coding Alert

Published on Fri Aug 07, 2009 PDF

Incident-to rules apply to the relationship between a physician and a mid-level provider.

Question: Is there any circumstance in which a group can bill all services and all providers (including other physicians) under just the medical director? I know we can bill NPP services incident-to another physician, but what about other physicians?

Answer: No, you cannot always bill services for all providers under a group's medical director. One reason is because you may not bill one doctor incident-to another doctor. Incident-to rules don't apply here because they pertain to the relationship between a physician and a midlevel provider (MLP), also known as a nonphysician practitioner (NPP).

Bottom line: It is never acceptable to bill services provided by one physician under another physician's name or national provider identifier (NPI). Billing under the name of a physician who did not perform the service could lead to allegations of false claims submissions.

You can, however, report MLP services incident-to the medical director if the visits meet all the requirements of incident-to services. The MLP could be a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist -- as long as the MLP meets state and federal guidelines to provide the service. The MLP 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.

Best bet: Check your state and local Medicare regulations for NPP  qualifications. If the NPP does not meet one or both sets of guidelines, don't bill incident-to for physicianlevel services (such as 99212-99215, Office or other outpatient visit ...).

Keep in mind: In order to bill the service under the medical director's NPI, there has to be a plan of care for the patient's condition (and the plan of care may have been developed by the patient's regular physician and not necessarily the medical director). Plus, the medical director must be physically on site  in the office suite when the MLP is providing the service you are billing.