When your physicians are out of the office, it’s easy to forget taking incident-to billing out of the lineup. Failure to do so, however, is a violation that can land your medical practice in hot water.
What is Incident-To Billing?
Incident-to billing refers to billing services provided by a nonphysician practitioner (NPP), such as a physician assistant, nurse practitioner, midwife, therapist, etc. Qualified NPPs can perform services under the name and National Provider Identifier (NPI) of the supervising physician—providing that the supervising physician is in the office. In this sense, the patient is under the physician’s care, with the NPP serving as a physician extender.
With the supervising physician in the office suite—and immediately available if called upon—medical practices can claim incident-to services performed by a NPP, code the services under the supervising physician’s NPI, and receive maximum allowed payout. The NPP, of course, must have an employment relationship with the physician or the physician’s employing agency.
When the physician is out of the office, services provided by the NPP must be reported under the NPP’s NPI. In this instance, the medical practice will receive only 85% of the allowed payout—which, tongue-in-cheek, is why it’s easy to forget to adjust NPP billing when the physician is away. It is definitely why the OIG, armed with penalties, is vigilant.
New Patient, New Problem
Other stipulations that limit NPP billing involve seeing a patient for the first time, which includes seeing an established patient with a new problem. Incident-to guidelines do not allow a NPP to file incident-to services under a physician’s NPI when a new patient or new problem is addressed. The NPP may see the new patient or attend to the new problem, but the visit must be filed under his or her NPI. Only after a supervising physician has establish a plan of care from a prior visit can the NPP serve as a physician extender.
Is the NPP limited in terms of the incident-to services he or she can provide? No, not if the NPP is qualified to perform the services. NPPs aren’t constrained to taking vitals and medical histories. As physician extenders, they can provide and bill incident-to services ordinarily performed by the supervising physician, so long as the supervising physician is on site. Some examples from Medicare’s Internet-Only-Manual (IOM) include reading X-rays, setting casts, minor surgeries… activities required for effective evaluation and/ or treatment of a patient’s condition.
A Final Caveat
Incident-to guidelines were developed by Medicare. Though Medicare tends to set the standard in the billing and reimbursement realm, not all payers follow suite. Some payers have state by state policies, as well, and may require all providers, NPPs included, to bill under their own NPI.
Always check with your insurance carriers before billing incident-to services.
Author bio: Deborah Marsh, JD, MA, CPC, CHONC, is a senior content specialist for TCI SuperCoder, working on everything from online tool enhancements and data updates to social media and blog posts. Deborah joined TCI in 2004 as a member of TCI’s respected Coding Alert editorial team.