Pulmonology Coding Alert

• NPP: If a nonphysician practitioner (NPP) performs an E/M visit for an established patient with no new problems, then the service may be billed under the supervising physician’s national provider identifier (NPI) if all incident-to requirements have been met.
• NPP (only): If only an NPP performs an E/M visit for an established patient with a new problem, then the service may be billed under the NPP’s NPI.
• NPP and physician: If an NPP and physician perform an E/M visit for established with a new problem, then the service may be billed under the physician’s NPI if the providers meet the incident-to requirements.

In addition to meeting the incident-to requirements for the NPP and physician visit, Noridian instructs that “Documentation must support a face-to-face occurred with physician (during the encounter) and that they have initiated course of treatment. Physician must sign their entry.”

Resource: https://med.noridianmedicare.com/web/jeb/topics/ incident-to-services

Do Incident-To Services Require Direct Supervision by a Physician?

Most of the time, yes, incident-to services do require direct supervision by a physician. However, the physician doesn’t have to be in the same room with the NPP, PA, or NP, while they are caring for the patient.

“The physician does have to be in the same office suite and immediately accessible. For Medicare patients, the requirements are clear that the physician cannot be on vacation and only available via phone,” Giangreco Brown says.

Direct supervision exceptions: “There are a couple of exceptions for non-face-to-face portions of services, like transitional care management (TCM),” says Maryann C. Palmeter, CPC, CPCO, CPMA, CENTC, CHC, director of physician billing compliance for University of Florida Jacksonville Physicians, Inc.

According to the CPT^® guidelines, TCM services “are for a new or established patient whose medical and/or psychosocial problems require a moderate or high level of medical decision making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility to the patient’s community setting (eg, home, rest home, or assisted living).”

TCM face-to-face services provided in the office must meet the same incident-to criteria as a standard office visit. TCM face-to-face services performed in the home must also meet incident-to criteria, which means the physician must also be present in the home during the advanced practice provider’s (APP’s) service. However, there is an exception that allows for general supervision when the patient resides in a location designated as a medically underserved area.

TCM is also composed of non-face-to-face services, and incident-to billing exceptions occur when a provider performs non-face-to-face portions of the service. According to the Medicare Benefit Policy Manual, Chapter 15, section 60.4.A, “the direct supervision criterion … is not applicable to individual or intermittent services outlined in this section when they are not performed by personnel meeting any pertinent State requirements … and where the criteria listed below are met.”

Section 60.4.A.2 clarifies that the service is “an integral part of the physician’s service to the patient, and is performed under general physician supervision by employees of the physician or clinic.” Medicare defines general supervision as meaning the physician doesn’t need to be physically present in the patient’s home or place of residence while the NPP, NP, or PA performs the service.

Bottom line: In medically underserved areas, you may report NPP, NP, or PA services during TCM as incident-to the physician if the provider performs services in the patient’s home without the physician there, as long as other incident-to requirements are met. Otherwise, the physician has to be on-site to bill under the physician’s name or the APP bills under the APP’s name.

How Can We Streamline Incident-To Documentation Review?

Medicare currently doesn’t require the physician to attest to providing direct supervision in the documentation. However, some Medicare contractors do require documentation of a comment by the APP that identifies the supervising physician or a physician co-signature. This means you should protect your practice with documentation in the event of an audit. “I advise practices to keep copies of clinic schedules in the event of an audit and to ensure that the physician who is supervising is not otherwise engaged in activities that would preclude him or her from being immediately available,” Palmeter says.

You should also consider the practice’s bottom line when billing for incident-to services. Some practices may opt to avoid manually reviewing the documentation to verify if the physician had an established treatment plan and established condition, and instead just bill the services under the NP or PA, depending on the individual payer’s policy and state requirements.

This practice could result in lower payments while also boosting the number of claims submitted. “While this automatically reduces the reimbursement for Medicare patients by 15 percent, it may pay off in the end to not have to have the cases manually to determine who the encounter should be billed under,” Giangreco Brown says.

Additionally, seeking higher reimbursement rates for services performed incident-to without regularly seeing the patient to keep up on the patient’s condition and treatment could be a problem in the long run. “Some practices allow the NPP to work pretty much independent of the physician but still want to take advantage of the higher reimbursement rate associated with incident-to billing. It can be a double-edged sword,” Palmeter adds.

Palmeter advises that practices to develop a policy that indicates how often a physician needs to see and evaluate a patient to show active involvement in the patient’s treatment for the problems that are being billed to that physician.