Practice Management Alert

Here are the requirements you have to meet.

If you’re wondering how to get that additional 15 percent reimbursement for service provided by non-physician practitioners in your practice, here’s how to do it AND safeguard your practice from compliance risks.

If the below “incident to” requirements are met, CMS pays the services rendered by qualified non-physician practitioners (NPPs) under the physician’s National Provider Identifier (NPI) as if the physician provided them.

To receive reimbursement at 100 percent of the fee schedule, NPP “incident to” care must be performed on an established patient and:

• Be an integral, although incidental, part of the physician’s professional service;
• Be commonly rendered without charge or included in the physician’s bills;
• Be of a type that is commonly furnished in physician’s offices or clinics; and
• Be furnished by the physician or by auxiliary personnel under the physician’s direct supervision.

CMS provides the following examples of a typical of “incident to” visit:

In an office setting, the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the ‘incident-to’ requirements are met, the physician reports the service. If the ‘incident-to’ requirements are not met, the service must be reported using the NPP’s NPI.

Face Time is a Must

CMS Transmittal 1875 adds this caveat: “if there was no face-to-face encounter between the patient and the physician, the service may only be billed under the NPP’s NPI.”

There might be instances where the physician’s notes don’t include the required face-to-face encounter. Maybe he only writes that he reviewed test results or scans and made recommendations; because the note doesn’t indicate the physician’s contact with the patient, you should bill this visit under the NPP’s NPI.

CMS provides the following example of a shared visit:

The NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service.

The Physician Must be Available to the NPP

The supervising physician does not necessarily need to be present while the NPP is performing services, unless such physical presence is otherwise required by the state law in which the NPP practices. The critical element is that the supervising physician be immediately available to the NPP for consultation by telephone. Evaluate your state law requirements to be sure that your NPP is operating within his or her scope of practice.

The following example demonstrates how the typical shared visit works: The NPP visits and examines a patient. The NPP documents her work establishing medical necessity. At a different time, the doctor sees the patient. The physician documents her work. This can be immediately after or even before the NPP’s visit, but it has to be on the same day. Then, you can add the documentation together to establish a billing level.

The documentation must prove the doctor provided at least one element of the encounter for you to bill under the physician’s NPI.

When submitting shared service claims, be sure to:

• Clearly identify both providers in the medical record
• Link the physician’s encounter notes to the NPP’s
• Include legible signatures from the physician and the NPP.

In many shared visits, the NPP conducts the preliminary interview and exam, and then the physician sees the patient. To bill a shared visit under the physician’s NPI, he must provide and document a face-to-face service.

To view Medicare’s Transmittal 1875 in full, please visit https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1875cp.pdf.