Using nonphysician healthcare providers (NPPs) such as nurse practitioners, occupational therapists, physician assistants, clinical nurse specialists, certified nurse midwives, and medical technologists to render services can enable your practice to treat more patients. While the use of NPPs can greatly enhance the efficiency of running a practice, physicians must make sure they follow the rules and guidelines to bill for the service of an NPP. Services from these providers are considered “incident-to” services.
According to Medicare, to receive reimbursement for “incident-to” of a physician, services, and supplies can be of any of the following:
- An integral, although incidental, part of the physician’s professional service such as seeing patient for follow-up visits, procedures, or X-rays;
- A commonly rendered service without charge or inclusion in the physician’s bill, e.g., the administration of patient-owned medication for an infusion;
- A type of service commonly furnished in physician offices or clinics, such as infusions in a rheumatology practice; or
- Furnished by auxiliary personnel—individuals are direct employees, leased employees or independent contractors of the physician—under the physician’s direct supervision.
- To help you sort out the coding and documentation guidelines for billing and documenting NPP services, below are two common scenarios that can cause confusion.
Scenario 1
An NPP sees a patient without the supervision of a physician, i.e., the physician is not on site.
Medicare does allow NPPs to see patients without physician supervision as long as state regulations allow for this service. However, in this scenario, the service cannot be billed under “incident-to” guidelines. The service would have to be billed under the NPP’s national provider identifier number and the charges would be reimbursed at 85% of the Medicare Physician Fee Schedule.
Scenario 2
An NPP sees an established patient and the patient presents with a new problem. There are two options to consider when faced with this scenario.
- Option A: The NPP can continue to treat the patient with no physician input and bill Medicare using their NPI number. This would be reimbursed at 85% of the fee schedule.
- Option B: The NPP would stop the visit and have the physician take over the visit including retaking the history of present illness. The physician would bill Medicare using his/her NPI number and would be reimbursed at 100% of the fee schedule.
(Note: The physician is not allowed to coparticipate in the visit to address or give an opinion concerning the new problem. This is considered a shared visit and is not allowed for office and outpatient services.)
Keep in mind that the above “incident-to” rules apply to Medicare reimbursement only. Private carriers may have different guidelines for reimbursement of NPP services. It is imperative for your staff to verify private payer coverage if a beneficiary is seen by an NPP.
Using the services of an NPP can be a great time saver and revenue booster to a practice, if all guidelines are followed. As always, documentation is the key to supporting all services performed in a practice, no matter who is performing the service.
For further information concerning “incident-to” guidelines or any coding matters, contact Melesia Tillman, CPC-I, CRHC, CHA at (404) 633- 3777, ext. 820, or [email protected].
