Practice Management Alert

Proper use of physician's NPI could get you paid in full.

With the current economic climate and physicians stretched to their max, many practices are turning to qualified nonphysician practitioners (NPPs) to see more patients. But if you don't know how to properly -- and compliantly -- bill these incident-to services, you could be bringing in just 85 percent payment for a service or even setting your practice up for fraud scrutiny.

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 her 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 be shorting 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. He or she should be in the office suite area," says Julie Keene, CPC, CENTC, with UC Health in Cincinnati.

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 check-up to 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. "So if the physician is down the hall, that qualifies as incident to," Keene explains.

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. This will net the practice about $65.67 without geographic adjustments (transitioned nonfacility relative value units [RVUs] multiplied by the current 2010 Medicare conversion rate of 36.0846). Using the NPP's NPI, the same visit would pay only about $55.82.

Note: There are other location restrictions as well. "Incident-to services are only truly applicable for Medicare patients unless you are provided rules in writing from a private payer that indicates that either they follow the CMS guidelines for incidentto providers or that they have their own rules," says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACSPM, CHCO, owner of MJH Consulting in Denver. Incidentto services are also not allowed in facility sites of services, such as for in-patient scenarios, Hammer adds.

Note: The supervising physician under which incident-to 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.

Roadblock: Some payers now require NPs and PAs to be credentialed, and bill under their own NPIs. The payer would then decrease payment accordingly to the 85 percent (or lower) level established by Medicare.

For example, Kansas Medicaid will not accept incident to billing for non physician providers. They also require all NPPs to credential with them and bill under their own number for all services.