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Incident to

Kathy Posted Thu 08th of August, 2013 13:12:36 PM

Will Incident to billing cause a red flag leading to a Medicare audit even if you document correctly?

SuperCoder Answered Thu 08th of August, 2013 13:19:33 PM

It's safer to get each payer's ruling on this matter in writing to avoid potential problems. For instance, you should find out from each payer if they allow incident to billing (which they probably do since they do not credential the SLP), and if they do allow it, do they require direct supervision (the physician in the office suite). If they require a doctor in the suite (direct supervision), make sure your claim comes from the doctor doing the supervision, not the doctor who ordered the services. Always get the information in writing on the payer's letterhead, because years later when the payer comes after your practice, the person who gave you the information will not be there and you will have nothing to back you up.

Always check the Medicaid guidelines in each state that you practice, and submit to their rules. Every state is different. For example, Kansas does not allow any incident to billing for NP and PAs and requires them to be billed out under their own NPI. They do not follow Medicare's rules. You cannot assume that any payers, including Medicaid, Tricare or any private payer follows Medicare's rules. Sometimes a state's Medicaid web site would specifically state that NPPs cannot bill incident to. If a doctor bills for the NPP under his name, he could end up in jail.

Medicare does not allow you to bill out your SLP incident to when the physician is not present in the office suite. The Medicare incident to rules must be followed which includes direct supervision.

SuperCoder Answered Thu 08th of August, 2013 13:24:06 PM

Also check below to understand Medicare requirement in this regard:

Resource: Visit the CMS website for more on coding incident-to services at

Having non-physician practitioners (NPPs) as part of your group can ease patient care loads, but brings its own share of challenges from a billing perspective. Here’s your refresher on how to correctly file incident-to claims and the full fee for your NPP – while staying away from extra scrutiny by the Office of the Inspector General (OIG).

Understand Incident-To Basics

According to Medicare’s incident-to rules, qualified NPPs can treat patients and (under certain conditions) bill the visit using the physician’s National Provider Identifier (NPI). That means the NPP will bring in 100 percent of the assigned fee for the service (more on these conditions under Step 2).

Remember: If you find the service does not meet incident-to billing requirements, you don’t have to forego payment altogether in many cases. If a Medicare credentialed NPP provides the service, you can bill under his own NPI. In that case, you’ll usually receive 85 percent of the normal fee found in the Medicare Physician Fee Schedule, for a nurse practitioner (NP) or physician assistant (PA).

Exception: If a member of your auxiliary staff, such as a medical assistant (MA), provides a service when there is no direct supervision, you cannot bill for the service, since the service does not meet incident-to requirements and auxiliary staff do not typically have their own NPI for Medicare billing purposes. “Direct supervision” means a supervising physician must be immediately available in the office suite during the service (assuming the service is provided in the office setting).

Check Off the Criteria

Before assuming incident-to applies, verify that the visit meets a few conditions. CMS’ Benefit Policy Manual (Chapter 15, Section 60) defines “incident to” as “services furnished as an integral, although incidental, part of a physician’s personal professional service.”

CMS pays an NPP office service reported under a physician’s NPI at 100 percent, provided you meet the following requirements:
•The NPP performs the service in a non-institutional setting (such as the physician’s office [place of service 11])
•The NPP performs the service within the scope of her practice and in accordance with state law
•The physician should establish the care plan for a new patient to the practice, or for any established patient with a new medical condition. NPPs may implement the established plan of care during a follow-up visit
•The physician must provide “direct supervision” when the NPP is rendering the service.

Reminder: As noted in the first criterion, do not report services rendered in a hospital setting — either outpatient, inpatient, or in the emergency department — as incident-to. Medicare doesn’t allow it for hospital services or care given in skilled nursing facilities.

No new problems: The physician must have seen the Medicare patient during a prior visit and established a clear plan of care. If the NPP is treating a new patient or a new problem for an established patient, or if the physician has not established a care plan for the patient, then you cannot report the visit as incident-to.

Check supervision: If a physician does not directly supervise the NPP for the encounter, the incident-to rules do not apply. The supervising physician, however, does not need to be the physician who initiated the treatment plan.

Bill in the name of the physician present in the office suite and providing the direct supervision at the time of the NPP visit, regardless of whether he initially saw the patient and developed the plan of care.

The physician supervising in the office goes in box 31. The physician who wrote the plan of care for the visit goes in 17” of CMS Form 1500. The NPP should include in their documentation, the name of the physician available for direct supervision during the service. This is not mandatory from a CMS perspective, but some Medicare contractors do require this information and/or the supervising physician’s signature on the note. Even if your payer doesn’t require the information, including it will assist in eliminating any confusion if the claim is questioned.

Watch out: Be familiar with your state’s laws governing the scope of practice for your different NPPs as well. Medicare guidelines specify that “coverage is limited to the services a PA or NP is legally authorized to perform in accordance with state law.

Watch for Extra OIG Scrutiny

The OIG states in its 2013 Work Plan the intention to review physician billing to determine whether payment for incident-to services had a higher error rate than that for non-incident-to services. The agency also intends to assess Medicare’s ability to monitor incident-to services, which the OIG considers “a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record.”

Incident-to billing is always something being scrutinized by the OIG simply by nature. The claims are sent in under the physician’s name. The mid-level provider is ‘transparent’ to this process. If the carriers see more claims than normal coming in for the physician, that type of specialty, etc. they will want to investigate to see if the patients are being seen appropriately and thus being billed appropriately.

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