Boost Revenue through Correct Incident-to Billing but Use Caution

Lea Chatham May 27th, 2014

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By Lisa A. Eramo

imagesWhen reported correctly, incident-to services can definitely boost a practice’s revenue. The bad news is that when reported incorrectly, these services can raise a red flag to auditors, Jean Acevedo, LHRM, CPC, CHC, CENTC, told coders at AAPC’s 22nd annual HEALTHCON conference in Nashville, TN last month.

During a presentation on maintaining compliance with incident-to billing, Acevedo called attention to a 2009 OIG report titled Prevalence and Qualifications of Nonphysicians Who Performed Medicare Physician Services. The report states that in the first three months of 2007, Medicare allowed $12.6 million for approximately 210,000 services performed by unqualified physicians—i.e., those lacking the necessary licenses, certifications, credentials, or training to perform the service. She said this report—as well as the subsequent inclusion of incident-to services in the 2012 OIG Work Plan—is proof that compliance concerns with incident-to services remain high.

What exactly are incident-to services?
To be as covered incident-to the services of a physician, services and supplies must meet all of the following criteria:

  • Be an integral, although incidental, part of the physician’s professional service
  • Commonly rendered without charge or included in the physician’s bill
  • Of a type that are commonly furnished in physicians’ offices or clinics
  • Furnished under the physician’s direct personal supervision
  • Furnished by an individual who qualifies as an employee of the physician

When practices bill services as incident-to, they receive 100% of the Medicare physician fee schedule (MPFS) amount. When services billed under the non-physician practitioner’s NPI, practices receive 85% of the physician fee schedule amount.

Who can perform services incident-to a physician?

  • Registered nurse (RN)
  • Licensed practical nurse (LPN)
  • Medical assistant (MA)
  • Technician
  • Physician assistant (PA)
  • Nurse practitioner (NP)
  • Physical therapist (PA)
  • Occupational therapist (OT)
  • Clinical psychologist (CP)
  • Licensed clinical social worker (LCSW)

Note that PAs, NPs, PTs, OTs, CPs, and LICSWs can also bill Medicare directly as opposed to billing incident-to a physician.

Acevedo urged coders to review the incident-to guidelines as well as the provider’s state-specific scope of practice and organization bylaws before billing incident-to services.

Consider medical assistants. “The overwhelming majority of states don’t allow a medical assistant to do something without direct physician supervision,” Acevedo said.

What if the scope of practice doesn’t align with requirements?
In some cases, a provider’s scope of practice won’t align with CMS benefit requirements. When this occurs, Acevedo said that the more stringent of the two requirements would apply.

For example, the Medicare Benefit Manual, Section 50.4.4.2 states that Medicare doesn’t require, for coverage purposes, that a doctor of medicine or osteopathy order the vaccine for pneumococcal pneumonia, influenza virus, or hepatitis B. The Benefit Manual further states that beneficiaries may receive these vaccines upon request without a physician’s order or supervision.

However, in some states, the scope of practice doesn’t allow medical assistants to perform this task at all or unless they operate under direct supervision of a physician. When this occurs, the state scope of practice trumps the Medicare requirement because it is the most stringent.

Per the Florida Department of Health, medical assistants cannot even take vital signs unless they operate under direct supervision of a licensed physician, Acevedo pointed out. Although this requirement may seem surprising, it couldn’t be clearer, and practices must abide by this, she said.

Coders should always be on the lookout for potential changes to incident-to billing and/or scope of practice published in the annual MPFS. For example, in calendar year 2014, Medicare revised its benefit for fecal occult blood testing to include coverage when the test is ordered by nurse practitioners, physician assistants, and clinical nurse specialists acing with their scope of practice and who are the patient’s attending nonphysician practitioner. Prior to January 1, 2014, this particular Medicare benefit only occurred when a physician ordered the test.

Practices should closely examine all documentation related to incident-to billing, Acevedo advised. Documentation should specify the following:

  • Specific individual who rendered the service
  • Whether and how supervision requirements were met
  • Physician initiation and continued involvement in treatment
  • Medical necessity for services rendered
  • Whether services are included in the nonphysician practitioner’s scope of practice

Acevedo said proving that supervision requirements were met could include something as simple as printing the physician’s schedule for certain dates of service to show that he or she was in the office.

She reminded coders that they cannot bill incident-to services for new patients, consultations, or established patients presenting with a new problem. Tweet this Kareo story

Incident-to services are also not appropriate for the inpatient setting or services provided at the patient’s home. Coders should not assume that a third-party payer recognizes a nonphysician practitioner’s services as incident-to. Always verify whether the payer includes nonphysician practitioners as covered providers, she said.

About the Author

Lisa A. EramoLisa A. Eramo is a freelance writer/editor specializing in health information management, medical coding, and healthcare regulatory topics. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal and AHIMA Advantage. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.

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