Incident to Billing. Incident-To. Charla Prillaman, CPC, CPCO, CPMA, CPC-I,CCC, CEMC, CHCO Breakout B4, Friday, 9/7/12

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1 Incident to Billing Incident-To SING REVENUES IN THE BUSINESS OFFICE Charla Prillaman, CPC, CPCO, CPMA, CPC-I,CCC, CEMC, CHCO Breakout B4, Friday, 9/7/12 Today s Objectives Increase understanding of the principle of incident to billing Identify whose services can be billed incident to Explain the difference between incident to and split/shared visits Compare the financial impact of incident to' vs. direct billing 2 1

2 Medicare Part B Concept Incident to billing is a Medicare concept. Some Medicaid payers may follow; many do not Most commercial payers require services provided by MLPs to be reported as if performed by the physician Some Managed Care payers will not empanel MLPs Your contract should outline who may bill for services 3 NC News PHYSICIAN ASSISTANT ENROLLMENT Physician Assistants will be required to enroll with North Carolina Medicaid effective November 1, All services rendered by Physician Assistants must be filed to Medicaid with their NPI as the rendering (or attending) provider. Applicants must meet all program requirements and qualifications for enrollment before they can be enrolled as a Medicaid provider. Each physician assistant shall sign participation agreement and enrollment application. Physician Assistants will not be allowed to bill incident to the physician after December 31,

3 OIG 2012 WORKPLAN We will review physician billing for "incident-to" services to determine whether payment for such services had a higher error rate than that for non-incident-to services. We will also assess the Centers for Medicare and Medicaid Services' (CMS) ability to monitor services billed as "incident-to." 5 The Importance of the Concept Incident to billing is invisible to payer. OIG report issued summer 2009 shows continued concern about this billing method. Direct billing of incident to services appropriately may have a significant impact on your bottom line. Billing incident to when criteria not met presents a significant compliance risk. Billing incident to services may present some customer service challenges. This concept can be confusing to patients. 6 3

4 Incident To Look A-likes Do not confuse these with incident to services Hospital split/shared visits Teaching Physician/Resident services Services with their own benefit category Must a supervising physician be physically present when flu shots, EKGs, Laboratory tests, or X- rays are performed in an office setting in order to be billed as incident to services? These services have their own statutory benefit categories and are subject to the rules applicable to their specific category. They are not "incident to" services and the "incident to" rules do not apply. Incident to denials 7 Incident to Requirements Typically performed in a physician s office Within the scope of practice of the person providing Employed by practice Physician has established a plan of care and is involved in patient s care Physician provides direct supervision 8 4

5 Professional Service By definition incident to a physician s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician s personal professional services in the course of diagnosis or treatment of an injury or illness Medicare 9 Benefit Policy Manual; Chapter 15, 60.1 Who may bill incident to Mid-Level Providers may bill incident to when all of the requirements are met (e.g., NP, PA, CNS, CNM) Auxiliary personnel including nurses, medical office assistants, technicians, or any employee who is acting under the supervision of a physician. Auxiliary personnel may provide 'incident to' services under physician or under MLP 10 5

6 Incident to and Place of Service Physician s office NOT provider based clinic (POS 22) NOT hospital NOT Skilled Nursing Facility If physician has rented office space that meets definition for pos 11 in a SNF Home visits can be billed as incident to if the physician is physically present to provide direct supervision 11 Employment Relationship Must represent an expense to practice Employed by the billing provider Part-time, fulltime employee Leased employee Independent contractor 12 6

7 To bill a service incident to... Physician must personally treat the patient on the patient s first visit for the problem & initiate a plan of care. Subsequent visits with MLP may be billed incident to. MLP can treat new patients and established patients with a new medical condition (within state scope of practice) but they must bill using their own NPI. May not bill these services incident to. 13 Carrier clarification of CMS language 14 Q- Are incident-to services allowed when an established patient is being seen based on an established treatment plan but during the course of the visit the patient indicates a new illness or problem in which the physician has not previously seen the patient? A- 'incident to' rules do not apply if there is a new illness or problem for which the physician has not previously seen the patient and there is not an established plan of care. The physician must remain actively involved in the patient's care and must periodically see the patient for the ongoing disease or illness. It is also recommended that the physician review the qualified practitioner's chart notes in order to monitor treatment progress. h/faq_coding.htm June, 2008 Cahaba 7

8 Incident to services are... typically performed in a physician s office within the scope of practice of the MLP Physician must be on-site (present in the contiguous office space) and immediately available to offer assistance. Bill incident to services using the provider number of the physician who provides direct supervision of the service. 15 Direct Supervision Physician must be present in the office suite at the time of service AND. Physician must be immediately available to assist if needed. 16 8

9 E/M Services billed Incident To & Documentation Physician Assistant (PA) Nurse Practitioner (NP) Clinical Nurse Specialist (CNS) Certified Nurse Midwives (CNM) Documentation should clearly link MLP service to the supervising physician. Evidence of the link may include: Co-signature & credentials of both MLP and supervising physician Notation of supervising physician s involvement within the medical record entry Documentation from other dates of service (initial visit) establishing the link 17 Define Office Suite Carriers have discretion to determine whether a specific scenario meets criteria Use reasonable judgment common sense in deciding where the supervising physician can be. Adjacent offices may meet the definition but Two offices separated by an atrium or parking lot or on different floors in the same building may not satisfy this requirement. Consider the availability component of the supervision requirement. Must be immediately available. 18 9

10 Direct Supervision is NOT... Available by phone, pager, does not constitute direct supervision Physician present somewhere in the building is not direct supervision Physician providing procedural care that cannot be interrupted 19 Who may supervise? Direct supervision may be provided by any physician in the group. The supervising physician is the physician immediately available at the time the service is provided. MLP may submit a claim using MLP NPI when supervising auxiliary staff providing incident to service. The billing physician must sign the note if auxiliary staff provided incident to service

11 Direct Billing MLPs can bill Medicare using their own provider number when incident to rules are not met (e.g., physician not immediately available, new patient, established patient with a new problem). If MLP has no Medicare provider number; there is no mechanism under which to be paid. Remember: The patient must be an established patient and have an established problem with a treatment plan in place in order to bill ''incident to''. 21 May never be incident to... A new patient visit An established patient, but with a new problem No supervising physician in suite and immediately available Patients seen in a SNF 22 11

12 Physician MLP under Physician s Number MLP Direct Billing 8/8/2012 Medicare Payment MLP services incident to a physician are invisible on the claim form and the claim is paid at 100% of the Medicare Physician Fee Schedule. MLP billing directly for services will be paid at 85% of the Medicare Physician Fee Schedule. 23 ~Compare ~ Compare reimbursement for previous scenarios Assume Physician Fee Schedule Values a Service at $100 Medicare $80 2ndary or patient $20 Medicare $80 2ndary or patient $20 Medicare $68 2ndary or patient $

13 Incident to or Direct? Dr. A s Medicare patient is scheduled for follow up for asthma. The patient is seen by MLP while Dr. A is evaluating another patient in one of the other exam rooms in the office suite. This is an incident to service. The appropriate level established patient E/M service may be submitted by Dr. A Reimbursement will be 100% of the physician s fee schedule approved amount 25 Incident to or Direct? Dr. A s Medicare patient comes in today for a scheduled follow up for asthma. The MLP sees the patient while Dr. A (solo practitoner) is making rounds at the hospital. The office is connected to the hospital by an over the road walkway. This is not an incident to service. The appropriate level established patient E/M service may be reported under the MLP s provider number. Reimbursement will be 85% of the physician s fee schedule approved amount 26 13

14 Incident to or Direct? Dr. A s patient comes in to receive her B-12 injection that Dr. A ordered. Dr. A is a solo practitioner and is at the hospital when the patient receives her shot. Ms. B, ARNP is seeing patients at the office. Ms. C, RN administers the injection and completes the appropriate medical record documentation. This is not an incident to service to Dr. A. It may be billed incident to Ms. B, ARNP. Who has to sign the nurse s documentation? RN & ARNP 27 Incident to or Direct? Dr. M s Medicare patient comes in today for his scheduled f/u for Asthma. MLP sees the patient and provides the appropriate E/M service. Dr. M is vacationing with his family in the Caribbean. Dr. C (another physician in the same group) is in the office suite and immediately available. This is an incident to service and can be submitted by Dr. C. Reimbursement will be 100% of the physician s fee schedule approved amount 28 14

15 Incident to or Direct? Dr. A s NORTH CAROLINA Medicaid beneficiary was treated (by Dr. A) for asthma in July It is now January 2012 and the patient returns for scheduled follow up for his asthma. Mr. Jones, PA cares for the patient following Dr. A s plan of tx. This is NOT an incident to service. Physician Assistants must direct bill NC Medicaid for services after 12/31/ Hawaii Medicaid and Physician Assistants (i) Hawaii Medicaid will reimburse physician assistant services if services are provided at the supervising physician s place of business. All claims for physician assistant services must be submitted by the employing physician

16 Incident to or Direct? An established Medicare beneficiary is scheduled with the MLP for follow up management of her HTN. The patient says By the way, my hair is falling out, and I am always tired; in fact I fell asleep at a red light yesterday. It really scared me. This is not an incident to service. Although this is an established patient, it s a new problem. The service should be billed directly by MLP. When a new problem results in MLP service billed under direct billing, all future visits by MLP for this problem will also be billed directly. There is no physician plan of care. 31 Shared Visits Physician and MLP both provide face-to-face medically necessary care for the same patient on the same date of service Employment = same group or employed by same employer POS = Hospital, ER, Hospital Observation, Hospital Discharge Does not apply to procedures or critical care services If physician s participation is reviewing medical record, service should be direct billed. Do not confuse with teaching rules. DOCUMENTATION must describe work personally performed by each 32 16

17 Shared Visit Example A Medicare beneficiary is in the hospital being treated for pneumonia. The MLP sees the patient in the AM making the appropriate care decisions and chart documentation (including signature). The physician sees the patient later in the day and provides medically necessary care; documenting & signing his/her care in the patient s medical record. A claim may be submitted to Medicare under the concept of shared services. One E/M service that accounts for the combined medically necessary work of both providers. Billed under the physician number. Reimbursement will be 100% of the physician s fee schedule approved amount 33 Commonly Called Nurse Visit Monitor Blood Pressure/Weight Read PPD-tuberculin test Supervise drug screen Lactation counseling Peak flow meter education Change dressings (Doctor is in Office Suite at time of Service) 34 17

18 Incident to or Direct? Dr. A s Medicare beneficiary was started on medication (by Dr. A) for hyperlipidemia & instructed to schedule an appointment for labs and counseling in 1 mo. The patient returns as scheduled and the RN spends 40 minutes of a 45 minute visit counseling the patient. Dr. A is seeing other patients in the office at this time. This is an incident to service. Submit claim using Dr. A s NPI. Because an RN is auxiliary staff, billing is limited to Reimbursement will be 100% of the physician s fee schedule approved amount 35 Incident to ~ Auxiliary Staff A Medicare patient comes to the office with complaints of coughing and a fever. Dr. A evaluates the patient (E/M) and orders an antibiotic injection. Dr. A s RN gives the antibiotic shot Dr. A would bill (therapeutic IM injection), the appropriate J code for the antibiotic and the appropriate level E/M service. Current CCI edits require modifier 25 appended to the E/M service in this scenario. Reimbursement will be 100% of the physician s fee schedule approved amount 36 18

19 SUMMARY Incident to services are billed as if the physician provided the service and require Physician established plan of care Scope of practice allows In the office setting An employment relationship Shared services are provided jointly by the physician and an MLP Reasonable, medically necessary and face to face Both providers record their personal work Both providers sign their portion of the medical record Reimbursement for incident to & shared services is at 100% physician fee schedule 37 19

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