Denials Chp 8 Incident-to-Guidelines & Shared Visits Flashcards
Incident-to Guidelines and Shared Visits
Incident-to Guidelines
Incident-to services are performed incident to the physician’s services. These can be services performed by the patient’s staff. For example, a nurse giving an injection. This service is performed by the nurse under the physician’s supervision. Incident-to services are also performed by midlevel providers known as nonphysician practitioners (NPPs), including physician assistants (PAs), advanced registered nurse practitioners (ARNPs), and certified nurse midwives.
To bill services incident to, the services must be as a result of the physician’s treatment plan and the physician must be in the office suite providing supervision. They do not need to be in the room, but they must be in the office to bill the services incident to (for example, a nurse administering an injection). If the physician was out of the office seeing patients at the hospital, the services could not be billed because the physician is not providing supervision. Incident to is not recognized in a facility setting.
Medicare has very strict guidelines, but other carriers may have different guidelines. It is imperative to understand Medicare’s guidelines but understand what other payers’ guidelines are. If you meet the requirements for incident-to billing, the claim is submitted under the physician’s name as if they personally performed the service and the reimbursement will be at 100 percent. Services performed by NPPs that are not incident-to are billed under the NPP’s own national provider identifier (NPI) number and reimbursed at 85 percent.
Many practices think that the NPPs cannot provide services on their own but that is not true. NPPs can provide services on their own. The only difference is that the claim is billed in their name and there is a reduction in reimbursement. For example, if a patient comes for a follow up as part of the physician’s treatment plan and is seen by the NPP, the service is billed under the physician’s NPI. If the patient comes in for a new problem, obviously it would not be a service that is part of the physician’s treatment plan since the patient is presenting with it for the first time. This service would be billed by the NPP and paid at 85 percent of the fee schedule.
Split/Shared Services
A shared/split visit occurs when an NPP and physician are involved in the same patient case. If performed in the office setting and the incident-to requirements are met, the service can be billed by the physician. If not, it is billed by the NPP. In the hospital inpatient, outpatient, and ED settings, if the physician performs a face-to-face encounter, the service can be billed by the physician or the NPP. If the physician only reviews the chart and discusses the case with the NPP, the service is billed by the NPP.
Split/Shared Services vs. Incident to Billing Services
*Shared/split services involve a physician and an NPP.
*A variation could be two physicians or two NPPs.
*Both the physician and NPP must separately document and sign the record.
*When physician and NPP, only one, typically the physician, bills for the service.
If a physician and NPP, physician bills 100 percent of MPFS payment, as opposed to the NPP’s 85 percent.
MCM Spells Out Documentation for Teaching Physicians
Medicare Claims Processing Manual (MCM), Chapter 12 provides general documentation instructions and common scenarios.
For purposes of payment, E/M services billed by teaching physicians require that they personally document at least the following:
That they performed the service or were physically present during the key or critical portions of the service when performed by the resident, AND
The participation of the teaching physician in the management of the patient.
CMS felt there were “duplicative requirements for notations that may have previously been included in the medical records by residents or other members of the medical team.”
In their efforts to “reduce burden and duplication of effort for teaching physicians,” CMS has made the following changes:
The medical record must document that the teaching physician was present at the time the service was furnished.
The presence of the teaching physician during procedures and E/M services may be demonstrated by the notes in the medical records made by a physician, resident, or nurse.
The medical record must document the extent of the teaching physician’s participation in the review and direction of services furnished to each beneficiary, and that the extent of the teaching physician’s participation may be demonstrated by the notes in the medical records made by a physician, resident, or nurse.
The accuracy of the documentation that shows the teaching physician’s involvement in an E/M service, along with the review and verification of the accuracy of notations included by residents and members of the medical team, are still the responsibility of the teaching physician.
Modifiers and Reciprocal Billing
Medicare providers work hard day in and day out. To ease the burden of managing vacations and time-off requests when they happen, ensure your practice has its ducks in a row on the rules about physician coverage.
There are two separate medical provisions for physician coverage. The first is reciprocal billing. This type of Medicare arrangement allows “covered visit services which the regular physician or physical therapist arranges to be provided by a substitute physician or physical therapist on an occasional reciprocal basis,” according to CMS guidance.
In other words: Suppose a physician, Dr. A, goes on vacation and arranges for a colleague in town, Dr. B, to provide services in his absence. Under a reciprocal billing arrangement, Dr. A can bill for the services Dr. B provided to Dr. A’s patients while Dr. A was on vacation.
Chapter 1, Section 30.2.10 of the Medicare Claims Processing Manual outlines this important service. Highlights from the CMS guidance include these key components of reciprocal billing:
1.The regular physician is unavailable to provide the service.
2.The patient has arranged, or seeks to receive, the service from the regular physician.
3.The substitute only provides services to Medicare patients for no more than a period of 60 consecutive days.
4.The regular physician submits the claim for the services using HCPCS modifier Q5 (Service furnished under a reciprocal billing arrangement by a substitute physician; or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area).
Exception: There are always exceptions to the rule under Medicare and reciprocal billing is no different. Should you be called to active duty in the Armed Forces, CMS waives the 60-day limit to reciprocal billing, and you may bill for services furnished under the arrangement for longer than the time otherwise allowed by the regulations.
For all the details from this section of the Claims Processing Manual go to www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf.
Know These Substitute Provider (Locum Tenens) Basics
Another possible solution is locum tenens (LT), which is defined in detail in Chapter 1, Section 30.2.11 of the Medicare Claims Processing Manual. This type of coverage refers specifically to a physician who substitutes for other physicians when they’re absent for things like illness, pregnancy, vacation, continuing medical education, and sabbatical.
NPI lowdown: It’s wise to remember that an LT is a substitute for a regular physician, not a temporary hire for a busy practice - LTs are not contractual employees. In fact, though they may have their own NPIs their services are always billed under the regular physician’s NPI.
“You can mention the locum’s NPI number in the records, but it is not a requirement. If you do, put the locum’s NPI in block 19,” notes MAC Noridian Healthcare Solutions LLC. “Always bill with the absent, regular physician’s NPI and make sure you reflect the locum in the documentation.”
60-day limitation: The arrangement always notes that an LT cannot work for more than 60 continuous days for the physician she is covering. That time period can include weekends, and the locum cannot skip days during that time and then continue after the agreed-upon 60 continuous days. However, “if the regular physician is part of a group with many doctors, the locum can come back and work for a different physician when his 60 days are up,” Noridian advises.
The only exception to this rule, similar to that of reciprocal billing, is when the regular physician is called to active duty, in which case the LT’s time of service can be unlimited.
MD or DO only: There are medical restrictions when hiring LTs for your practice. CMS requires that the LT be an MD or DO, and there are no exceptions. “Non-physician practitioners cannot have locum during their absences,” says Noridian. In addition to medical specialists like cardiologists, urologists and others, an LT can also be utilized in the areas of general medicine, osteopathy, podiatry, dental surgery, optometry, and chiropractic services.
Tip: It’s important to remember that an LT can be substituted for a “hospice patient’s attending physician,” but modifier GV Attending physician not employed or paid under arrangement by the patient’s hospice provider must be attached to the code along with modifier Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician; or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area.
Take Care With Modifiers
It’s critical to bill under the name and absent physician’s NPI number to avoid denials. You need to append modifier Q6 to any code you’re using to cover the LT’s care.
Though they may look familiar, there is a huge difference between modifiers Q5 and Q6. The difference between the modifiers is that Q6 is applicable to locum tenens arrangements more than the federally qualified arrangement for which Q5 is used. Remember, Q5 is used for reciprocal billing arrangements.
Question: What is incident-to billing?
Answer: Incident-to billing is billing for services or supplies that are furnished incident to a physician’s professional services when 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.
Remember that incident-to billing is a Medicare convention; third-party payers have no similar universal policy that applies to all its carriers. Third-party payers might have their own incident to rules that emulate — or even duplicate — Medicare’s rules. If you have any doubt as to whether a third party allows incident to, check with the payer.
Question: How does incident-to billing affect reimbursement?
Answer: Done correctly, incident-to billing can add 15 percent to a practice’s bottom line when an NPP performs incident-to services.
How? If you bill an incident-to service to Medicare, the NPP will be able to bill under the supervising physician’s NPI, resulting in 100 percent reimbursement for the code. NPPs that file services under their own NPIs only get an 85 percent return on reimbursement.
Question: Do NPPs have to be follow a physician’s established plan of care to bill incident to?
Answer: Yes. To qualify for payment under Medicare’s incident-to guidelines, services must be part of the patient’s normal course of treatment, during which a physician personally performed an initial service, establishes a plan of care and remains actively involved in the ongoing course of treatment.
This makes perfect sense when you break it down logically.
If you think about the term incident to, it means that the services of the NPP are incidental to the physician’s services and plan of treatment. The services must be part of the physician’s services to diagnose or treat the injury or illness and be provided under a physician’s direct supervision.
Question: Incident-to billing is only possible when an NPP is working under direct supervision of a physician. What is direct supervision?
Answer: This is an area that often causes confusion. If you want to bill under the supervising physician and be paid at 100 percent of the allowable amount, a physician with the practice must be in the office suite.
For example, the physician cannot be across the street, three blocks away, or available via cell phone — but must be in person.
Question: So, if there is no direct supervision by a physician, incident-to billing is not possible?
Answer: That is correct. If any one of the requirements for incident-to billing are not met for services provided by an NPP, those services should be billed to Medicare directly under the NPP’s name and provider number.
Question: For incident-to billing purposes, who qualifies as an NPP?
Answer: Medicare has a list of NPPs that it allows to bill incident to the physician. Remember, for a full list of qualifying providers, refer to the Medicare 855I application at https://www.cms.gov/.
For private payers that have incident-to style billing rules in place, check your contract for a list of eligible NPPs.
Question: Are incident-to services for E/M services only?
Answer: Yes, incident-to rules only cover E/M services directly related to the problem in the established plan of care; if the NPP performs any procedures — or addresses a new problem during an E/M — incident-to billing is no longer possible.
Not only are procedures banned from incident-to. Incident-to services are specific to certain E/M services. Incident-to is not applicable to:
New patient office visits
Established patients being seen for new problem/condition (physician has not seen patient and established care)
Consultation services
Services performed in an institutional setting (i.e., hospital inpatient/outpatient, emergency department [ED], skilled nursing facility [SNF])
Best bet: If you have any doubt as to whether a service is billable incident to, check with your Medicare payer to be sure.
