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Ob-Gyn Coding Alert

CNM Services:

Four Elements Determine When to Bill Medicare Incident-To

With the HHS Office of Inspector General scrutinizing "incident-to" billing, ob-gyn practices must comply with strict guidelines to ensure proper reimbursement from Medicare for services provided by their certified nurse-midwives (CNMs). Otherwise, they could face exorbitant fines, penalties and repayments. Many ob-gyn practices have enhanced their services by using CNMs to deliver care for ob patients, says Karen S. Fennell, RN, MS, a senior policy analyst for the American College of Nurse-Midwives. The CNMs may also provide Medicare-reimbursable services to the elderly and patients with disabilities. Specifically, Medicare pays for roughly 50,000 births for women with disabilities each year, Fennell says. According to Medicare, incident-to services or supplies are those furnished as an integral, although incidental, part of the physician's personal, professional services in the course of a diagnosis or treatment of an injury or illness.

"Typically, however, the patient delivering the baby will most likely have insurance coverage other than Medicare," says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a national healthcare consulting firm based in Lansdale, Pa. "Other payers may not recognize CNMs as direct billers. It is very important that ob-gyn offices check with their local third-party payers to determine their respective billing guidelines concerning CNMs, particularly when incident-to does not apply."

You should report CNM incident-to services under the ob-gyn's personal identification number (PIN) on the CMS 1500 form as if the physician performed them. Medicare carriers will reimburse these services at 100 percent of the Physician Fee Schedule. Alternatively, CNMs may bill services that fall within their scope of practice as defined by state law directly under their own name and PIN. Medicare pays covered CNM services at the lower of the actual charge or 65 percent of the fee schedule for a participating physician, Falbo says. "Payment for these services is made only under assignment," she adds. Is It Really Incident-To? Medicare provides four guidelines to determine if a service or procedure is incident-to. If the service does not meet these requirements, you should report it under the CNM's PIN. 1. Incident-to services must be an integral, although incidental, part of the physician's professional services. This means that the ob-gyn must be involved with the patient's care, Fennell says. The physician must see the patient first to establish a course of treatment. He or she can then delegate subsequent care and services, which can be billed incident-to. The doctor must also initially treat established patients who present with a new problem or condition. Ob-gyn practices may often find that they have slipped away from this standard. Ob-gyns and CNMs may slide into a more casual approach, especially with established patients. This can lead to the CNM seeing patients without the [...]

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