Nonphysician Providers & Incident To Checklist

Check state laws PLUS this crucial document.

In last week’s Coder’s Cranium, we started a checklist of 3 things you should know to correctly bill for a nonphysician practitioner’s services — and stay compliant. This week, we complete the checklist with advice for items 4, 5 & 6.

4. Have You Distinguished Auxiliary Personnel From NPP Services?

NPPs can supervise auxiliary personnel (registered nurses [RNs], licensed practical nurses [LPNs] and technicians) for incident-to services just as a physician would supervise the NPP.

The catch: You must bill the auxiliary personnels services under the NPPs number, and you may only receive 85 percent reimbursement. For example, the physician is out of the suite doing rounds in a hospital while a PA sees patients in the suite under her provider number. A patient comes in for a blood draw, which a nurse on staff performs. The nurse should bill 36415 (Collection of venous blood by venipuncture) under the supervising PA’s provider number.

Watch out: State license laws determine the scope of practice under which NPPs can operate. So be sure to check your states licensure policy on incident to as well as other services (such as their ability to prescribe) because the scope of practice may not align with Medicare. The stricter set of laws takes precedence.

Do this: In addition to checking your state laws, check the Internet Only Manual (IOM) online for specific guidelines on different NPPs scopes of practice. Refer to Section 130 for a CNM, 110 for a PA, and 120 for an NP. For general incident-to guidelines, see IOM, Section 30.6.4.

5. Does the Documentation Demonstrate the Above Points?

Unless your NPP mentions all these key factors in the documentation, you can only expect 85 percent reimbursement.

Tip: The physician should document in his care plan that the patient will follow up with the NPP for monitoring of that particular episode of care. That care could be managing diabetes mellitus, hypertension, coronary artery disease or other conditions. When there is a new problem, however, the physician must see the patient and modify the plan of care for the NPP to follow accordingly.

6. How Can You Determine Which Physician Is the Supervising Physician?

CMS has clarified that the supervising physician does not need to be the same physician who authored the patient’s plan of care. Therefore, when your group practice has multiple doctors in the suite at once, you should devise a method for choosing which one to list as the supervising physician. One idea is to designate a particular physician as the supervisor for all incident-to services on a particular day, and then rotate physicians each day.

Compensation: Remember, in a group practice, the billing number listed on the claim determines which physician receives compensation from the practice for those incident-to services. If a doctor’s billing number goes on an incident-to claim simply because she happened to be in the office when the services happened, she’ll get credit for services that she didn’t order. Essentially, she’ll make more money, and the doctor who actually ordered the services will make less.

CMS hasn’t offered any guidance on how best to track incident-to services internally. Instead, each practice must figure out a way to base payment for incident-to services on the ordering physician, rather than the supervising physician.

Know the right boxes: You should list the ordering physician’s name in Box 17 on the CMS-1500 form and his NPI/UPIN in Box 17A. The supervising physicians NPI/UPIN goes in Box 24K, and her signature goes in Box 31. Finally, the groups identification number will go in Box 33. To ensure fair physician payment, you should base compensation on the physician listed in Box 17 — not Boxes 24K or 33.

From Part B Coder’s Rule Book. Available online at www.supercoder.com.

AUDIO: What many practices don’t know about flu shots, EKGs, Laboratory tests, and X-rays as “incident-to” services. And much more from Steve Verno.

Related articles:

1. Nonphysician Providers and Incident-To: Your Coding Questions AnsweredHere’s why you should keep your physicians’ work schedules on…
2. Use This Incident-To Checklist to Breathe Easy During an Audit You don’t need to second-guess the way you bill…
3. Steer Your Incident-To Coding Using These 4 Questions 100 percent pay possible if NPP follows internist’s care…