How to Bill Incident To When Carriers Guides Are Inconsistent
Published on Mon Nov 01, 1999
With 39 percent of the family practices in the U.S. using some type of non-physician provider (NPP: nurse practitioners [NP] and physician assistants [PAs]), correctly billing for their services has become more important than ever, according to Ron Nelson, PA-C, representative to the American Medical Associations (AMA) CPT Healthcare Professionals Advisory Committee and president of the American Academy of Physician Assistants.
Incorrect billing for NPP services cannot only cause a loss of significant revenue for family practices but also can raise a red flag to auditors, which could lead to repayment of previously overpaid claims.
NPP services can be billed in one of two ways: either as incident to your family practitioners service or by using the NPPs personal identification number (PIN).
Incident to vs. NPP PIN
When a service is provided to a patient by an NP or PA and is considered incident to the physicians service (see guidelines below), it should be billed under the doctors provider number as though the physician actually performed the service. Accordingly, it is reimbursed at the same fee schedule as the family practitioner. On the other hand, Medicare will accept billing under an NPPs own PIN number, but will only typically pay about 85 percent of the physicians fee schedule.
Incident to is defined by Medicare as services or supplies that are furnished as an integral, although incidental, part of the physicians personal professional services in the course of a diagnosis or treatment of an injury or illness. In addition, Medicare outlines four requirements for conforming to incident to:
1. Services and supplies must be those offered in the physicians office or clinic. Accordingly, non-physician providers cannot bill incident to for performing hospital rounds or following up on an inpatient. If NPPs are seeing patients in the hospital, they have to bill for their services under their PIN.
2. Services must be commonly rendered without charge or included in the physicians bill. The services provided by the NPPs must be in the realm of services that the family practitioner would customarily provide in an outpatient/office setting.
3. Physicians must provide direct personal supervision to auxiliary personnel. Direct supervision encompasses two areas:
a. Physician availability: The family practitioner does not need to be in the same room as the NPP while he or she provides services, but the doctor must at least be present in the office. Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in Augusta, GA, and the American Academy of Professional Coders 1998 Coder of the Year, reminds family practitioners that if the service is billed under the physicians PIN as incident to, the doctor must be able to prove that he or she was in the office and available to the NPP. Carriers may check your [...]
