Three Guidelines to Cull Out Deserving Dollars

Three Guidelines to Cull Out Deserving Dollars

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

You could end up confused if you do not totally understand incident-to rules. However you cannot afford not to Medicare reimburses at 100 percent of the physician fee schedule when services are billed in the doctor's name as an incident-to service, and 85 percent when billed under the NPP's name if incident-to guidelines are not fulfilled.

Thankfully, you have ways to boost your knowledge about incident-to-services. Here are three key guidelines:

Meet CMS-set criteria

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

The NPP carries out the service in a doctor's office

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 just-in patient or any established patient with a new medical condition. Non-physician practitioners may implement the established plan of care.

The doctor must be on site when the NPP is providing the service. Here's a must: The doctor should carry on 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 doctor must retreat the patient for the carrier to still think about the doctor's role as active. Document supervision Since year 2008, the agency has pushed for the doctor to document his approval of an NPP to provide follow-up services. For instance: Your otolaryngologist diagnoses a just-in 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 doctor or practice's nurse practitioner (NP). The initial physician service in this instance is reported as 99203 under the physician's NPI, which pays about $103 in reimbursement based on the Medicare fee schedule non geographically adjusted. What's more, follow-up services provided by the NPP which might be reported (for instance 99213) under the doctor's NPI, after being provided as 'incident to' the doctor's plan of care. The NPP should provide evidence of the necessary physician supervision. This can be achieved easily through a simple notation in the record. A co-signature is not needed for billing purposes, however may be called for licensure issues involving physician assistants or as required by the state. Know about NPP limitations When a patient comes to the office when no doctor is around, the NPP can see and tend to her. The NPP can also 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 not the doctor's, NPI. Medicare woll pay for the service at 85 percent of the fee schedule. Advice: As far as non Medicare payers are concerned, you should get in writing what their NPP policies are. It is important that you ask these questions: 1) Do they allow incident to billing? 2) Do they follow Medicare guidelines? (3) Do they credential NPP's with their own provider number for that payer for you to bill out the NPP individually? It is important that you know these information for each of your payers. You should not think that every payer follows Medicare's rules. This covers your state Medicaid program. Many Medicaid programs have their own individual NPP billing and credentialing rules different from Medicare and don't necessarily accept incident billing. Choice: By definition, a practice cannot bill a just-in patient visit or for a just-in condition carried out by a PA or NP under the supervising doctor's NPI. Likewise, by definition, a practice can't bill any patient visit carried out by a PA or NP under a doctor's NPI number as incident to. In its place, you must submit the claims with the NPP's NPI. For more on this and for other medical coding updates, sign up for a one-stop medical coding guide like Supercoder.

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