Understand 'incident To' Rules Properly

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The CMS recognizes non-physician practitioners (NPP) for payment purposes by reimbursing physicians for services provided 'incident to' a physician's care. But then, the agency has made it clear in 2008's Transmittal 87 that payers will not reimburse these services unless there is physician documentation authorizing the incident-to service.


If you are not fully aware of the incident-to rules, you could end up dazed and confused. However you can't afford not to - Medicare reimburses at 100 percent of the physician fee schedule when services are billed in the physician's name as an incident-to service, and 85 percent when billed under the NPP's name if incident-to guidelines are not met.


Thankfully, you have ways to boost your knowledge about incident-to-services. Take a look at these three key guidelines.


Meet CMS-set criteria


CMS' benefit policy manual defines 'incident to' services as 'services furnished as an integral even though incidental part of a physician's personal service. The agency pays NPP office service reported under a physician's NPI ...
... at 100 percent, provided of course you meet these requirements:


The NPP carries out the service in a physician's office (place of service 11)
The NPP carries out the service within the scope of her practice and in accordance with state law.
The doctor should establish the care plan for the new patient to the practice or any established patient with a new medical condition. NPPs may implement the established plan of care.
The physician must be on site when the NPP is providing the service.


Important: The doctor should continue to see the patient at a frequency reflective to the ongoing management of the patient's plan of care as defined by state law. The agency has no set time period for how long in between episodes the physician must retreat the patient for the carrier to still think about the physician's role as active.


Document supervision


Since the year 2008, CMS has pushed for the physician to document his approval of an NPP to provide follow-up services.


For instance: Your otolaryngologist diagnoses a new patient with acute sinusitis (461.9), and billed the service with 99203. His plan of care includes follow-up services to assess the patient's medication compliance and response. These services may be provided by the physician or practice's nurse practitioner (NP)


The initial physician service here is reported as 99203 under the physician's NPI, which pays about $103 in reimbursement based on the Medicare fee schedule non geographically adjusted (3.03 RVUs multiplied by 2011 conversion factor of 33.9764). In addition, follow-up services provided by the NPP which might be reported (for instance 99213) under the physician's NPI, after being provided as "incident to' the physician's plan of care.


The NPP should provide evidence of the required physician supervision. This can be easily accomplished through a simple notation in the record. A co-signature is not necessary for billing purposes; however may be required for licensure issues involving physician assistants or as called for by the state.


Know NPP limitations


When a patient visits when no physician is there, the NPP can see and tend to her. The NPP can even provide a service within his or her state law guidelines for scope of practice so long as the state's supervision requirements are met. But then in this case you should bill the services out to Medicare under the NPP's own NPI and the physician's NPI. Medicare will compensate for the service at 85 percent of the fee schedule.


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