incident to provider based

luvbuix

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i work for a large oncology practice that has a hospital system doing their coding for them. the coding is provider based & the setting is an outpt clinic within the hospital. my question is: how is incident to handled in this situation? at this time the hospital is not billing incident to even though we have many APPs seeing pts as incident to. any suggestions??
 

Pam Brooks

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The concept of incident-to doesn't apply in the outpatient facility setting. That's a concept only if you're reporting POS 11 (office) and only for Medicare. Otherwise, you have two choices depending on your payer mix.
Professional services done by an NPP (for Medicare) can either be split/shared or billed under the NPP's NPI number. If split shared, both the MD and the NPP must see the patient, document each their own significant portion of the service, and then bill under the MD. Otherwise, the NPP sees the patient independently, documents their note and you'd bill under the NPP. Commercial payers may require a billing provider if they don't credential NPPs, but many of these commercial payers don't recognize 'incident-to'. Most organizations tend to follow Medicare guidelines, but it's an organizational choice; still for Medicare patients you have to follow their guidelines regarding billing under the appropriate NPI.

Bottom Line:
Medicare Patient
1. Split Shared Visit or
2. Bill NPP's NPI number
Commercial Patient
1. Follow Medicare or
2. Bill MD as supervising

The challenge will be if you Bill the MD as supervising to NOT do that for Medicare patients.
 

luvbuix

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it should matter how the hospital is billing right? they are using rev code 0982 & billing on HCFAs. would rev codes 0510 or 0983 be more specific? what about from a compliance standpoint? do we need to have the supervising provider's name on all our office notes regardless of the billing situation?
 

thomas7331

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it should matter how the hospital is billing right? they are using rev code 0982 & billing on HCFAs. would rev codes 0510 or 0983 be more specific? what about from a compliance standpoint? do we need to have the supervising provider's name on all our office notes regardless of the billing situation?
Revenue code 0982 is not interchangeable with 0510 - 098X is for a professional fee and 0510 is for a facility fee. Some commercial payers may not accept revenue code 0510 on the UB-04, in which case the facility may roll both fees together and bill them on the 1500 form. There are very few payers around that still accept professional fees billed on a UB-04 form - I would be surprised if the hospital is billing this way to many of its payers - most will require the professional fees on the 1500 form.

Regardless of how it is billed, I agree with the post above - professional services performed in a facility can't be billed 'incident to', they can only be billed with the credentials of the provider who actually performed the service. 'Incident to' requires that the billing physician be the owner of the practice and the employer of any staff performing those services, which is not the case for a hospital-based practice.
 

luvbuix

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Revenue code 0982 is not interchangeable with 0510 - 098X is for a professional fee and 0510 is for a facility fee. Some commercial payers may not accept revenue code 0510 on the UB-04, in which case the facility may roll both fees together and bill them on the 1500 form. There are very few payers around that still accept professional fees billed on a UB-04 form - I would be surprised if the hospital is billing this way to many of its payers - most will require the professional fees on the 1500 form.

Regardless of how it is billed, I agree with the post above - professional services performed in a facility can't be billed 'incident to', they can only be billed with the credentials of the provider who actually performed the service. 'Incident to' requires that the billing physician be the owner of the practice and the employer of any staff performing those services, which is not the case for a hospital-based practice.
We are a physician owned practice functioning within hospital walls. All of the employees work for the practice not the hospital. Rather than having their own coding staff the hospital does the billing. We are affiliated with the health system but not employees of it. That is my issue- just want to be sure everything is in compliance at this point.
 

thomas7331

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We are a physician owned practice functioning within hospital walls. All of the employees work for the practice not the hospital. Rather than having their own coding staff the hospital does the billing. We are affiliated with the health system but not employees of it. That is my issue- just want to be sure everything is in compliance at this point.
I assume then that you're just leasing space from the hospital and the physician bears all of the costs of the practice, correct? If that is the case, then yours is not considered a provider based practice. Your services should be billed just as if you were billing in a physician office practice, on a 1500 form under your own TIN and with place of service 11. The hospital would not bill any services on the UB-04.

'Incident to' would apply just as it would in an office setting - if your practice chooses to do that and the requirements are met, you could bill your mid-level services under the supervising provider's credentials. If you wish to bill that way, you can instruct the hospital coders to do it that way. These are your practice's claims and they are ultimately your practice's responsibility, so you should be auditing the hospital's coders to ensure they're doing it the way you want them to.
 

SharonCollachi

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I assume then that you're just leasing space from the hospital and the physician bears all of the costs of the practice, correct? If that is the case, then yours is not considered a provider based practice. Your services should be billed just as if you were billing in a physician office practice, on a 1500 form under your own TIN and with place of service 11. The hospital would not bill any services on the UB-04.

'Incident to' would apply just as it would in an office setting - if your practice chooses to do that and the requirements are met, you could bill your mid-level services under the supervising provider's credentials. If you wish to bill that way, you can instruct the hospital coders to do it that way. These are your practice's claims and they are ultimately your practice's responsibility, so you should be auditing the hospital's coders to ensure they're doing it the way you want them to.

I think that's the heart of the issue here... it isn't clear (at least to me), if they are considered an office or not. The OP says "affiliated with but not employees"... what does that mean exactly? They also said "outpatient clinic within the hospital". Are you leased space or are you something else? Are you outpatient hospital?
 

luvbuix

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that means we have a contract with the hospital to provide the space & the coding with their own employees that they pay. the entire practice is independent (not health system owned)(doctor owned & operated) & we all work for & are paid by the practice. we see pts. for clinic visits- we don't do any surgery or hospital procedures. we provide office follow ups, chemo, & radiation in our clinics. all of our clinics are located in hospitals. you have to go to the hospital & go into the hospital building to get to our offices.
 

SharonCollachi

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Here is what is confusing... you are talking about revenue codes. If you truly are just a doctor's office, then there are no revenue codes, no facility fees, etc. If you are not part of the hospital, then you only bill CPT codes.
 

thomas7331

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that means we have a contract with the hospital to provide the space & the coding with their own employees that they pay. the entire practice is independent (not health system owned)(doctor owned & operated) & we all work for & are paid by the practice. we see pts. for clinic visits- we don't do any surgery or hospital procedures. we provide office follow ups, chemo, & radiation in our clinics. all of our clinics are located in hospitals. you have to go to the hospital & go into the hospital building to get to our offices.
It sounds to me like you are not provider-based. If you were provider-based, you would certainly know this, and you would have a sign in your office to that effect and would be required to notify all of your patients that you are part of the hospital for billing purposes.

If that's the case and you are in fact not provider-based, then Sharon is correct - you can only bill just as if you were a free-standing office. There would be no hospital charges, no UB-04 forms, and the coding and billing rules are exactly the same as if you were not located in the hospital. Even if the hospital staff is doing the coding for your practice, it is still be your practice's ultimate responsibility to ensure that they are doing it correctly and in accordance with your instructions and policies, just as if you had hired an outside billing company to do it for you.
 

luvbuix

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so- the coders are on production & just pretty much do the claims as they fall into the work que. so they do not check for any incident to. they bill office visits with a TC for their facility charge. for office they will just add a 25 mod if it is done with radiation or chemo without checking office notes as they are on production. don't know if that helps with the incident to issue or not. regardless of the contract/setting/billing issue i'm still wondering if the documentation has to include incident to statements just from a compliance standpoint??
 

kseebeck

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so- the coders are on production & just pretty much do the claims as they fall into the work que. so they do not check for any incident to. they bill office visits with a TC for their facility charge. for office they will just add a 25 mod if it is done with radiation or chemo without checking office notes as they are on production. don't know if that helps with the incident to issue or not. regardless of the contract/setting/billing issue i'm still wondering if the documentation has to include incident to statements just from a compliance standpoint??
If your practice is generating revenue from submitting CMS-1500 claims to Medicare Part B, you would be able to bill "incident-to" in an outpatient setting (Place of service (POS) 19 or 22). I recommend you check Box 24B on your claims verify what POS code you are billing. It does not hurt to document the presents of a supervising physician. However, there is a lot more to the "incident-to" rules than the presents of a supervising physician. See attached CMS manual Ch 15, Section 60. Your Medicare Administrative Contractor (MAC) webpage should have good resources for the "incident-to" rule.

Based on your description of how the coders work, I would be concern if they are coding appropriately. Adding modifier without review sounds concerning unless they have a good coding process in place. Modifiers TC and 25 are not relevant to "incident-to" billing.

I highly recommended that the practice have an external audit completed to identify any coding or billing errors that are coming from the hospital coding team. Your practice would ultimately be responsible for any errors billed under your Tax ID or NPI if you were by CMS.
 

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  • CMS Medicare Benefit Policy Manual, Chapter 15, Section 60.pdf
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thomas7331

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so- the coders are on production & just pretty much do the claims as they fall into the work que. so they do not check for any incident to. they bill office visits with a TC for their facility charge. for office they will just add a 25 mod if it is done with radiation or chemo without checking office notes as they are on production. don't know if that helps with the incident to issue or not. regardless of the contract/setting/billing issue i'm still wondering if the documentation has to include incident to statements just from a compliance standpoint??
You've said in previous posts that your practice is operated independently from the facility, yet you say here that the coders are adding modifier TC for 'their facility charge'? What codes are they adding this modifier to? It's not their facility charge if it's being done in your office, and in any case, a facility charge would go on a UB form and would not have a TC modifier. It really sounds like there's something not right here.

As for the 'incident to' issue, you've said they are not checking for 'any incident to', but you haven't said which provider they are actually putting on the claim, the NPP or the supervising physician. The safest thing is if the claims are only being billed under the actual performing provider, which would be compliant in all situations, though it may cost your practice lost revenue if the 'incident to' requirements are actually being met. If that's the case AND you are billing an office place of service, then these can be billed under the supervising provider if your practice wishes. However, if you're billing a facility place of service, then you can only bill under the provider who actually performed the services. (The post above is incorrect on this - you cannot bill Part B 'incident to' in a facility location.)

It's really hard to advise you on this without being there to look at the documentation and claims. I agree with the last post in that you really should have a compliance auditor (preferably someone with experience in facility and provider-based billing) give this a careful look and make sure this is being done correctly.
 

luvbuix

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well- in this setting i am the compliance auditor. i have conflicting info from various sources telling me how it should be done. i am familiar with incident to & when & how it should be applied- i was just looking for clarification for this situation. i can't say this info cleared anything up for me but it's always good to have these conversations! thanks to all for your input!
 
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