The guideline for a separate and distinct new complaint or problem is often overlooked when treating established patients. This is an issue the Medicare program focuses on when auditing and reviewing claims. As a result, rheumatology practices should develop policies and procedures to ensure that all incident-to services are billed appropriately.
Direct vs. General Supervision
One of the most misunderstood aspects of the incident-to billing rules is the requirement for direct physician supervision. Many state laws permit advanced registered nurse practitioners (ARNPs) and physician assistants (PAs) to furnish healthcare services to patients without a physician’s on-site presence or direct supervision. Some state laws also permit general physician supervision (each practice will need to verify what is or is not permitted in their state). General supervision is defined as, “the procedure [or service] is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure.”3
However, under CMS regulations, incident-to services must be furnished under a physician’s direct supervision. Direct supervision means a physician must be immediately available to provide assistance and direction while an NPP is providing services that will be billed as incident-to. Although the physician does not have to be in the same room, the physician must be in the same office suite. By far, this is the incident-to billing requirement that physicians and their group practices misunderstand and fall prey to in audits. Unfortunately, the confusion is when practices comply with their state law supervision requirements instead of CMS’s direct supervision requirements for incident-to billing. For example, in Florida, ARNPs and PAs can practice under the general supervision of a physician; unfortunately, the general supervision requirements for ARNPs or PAs under Florida law (and most likely in many other states as well) don’t satisfy the direct supervision requirements for incident-to billing under the Medicare program. Therefore, it’s imperative rheumatologists and their office staff understand the difference between general and direct supervision.
Additionally, practices must ensure that their NPPs are licensed or certified to practice in the applicable state before they permit them to render services and bill them as incident-to.
Policies, Procedures & Compliance Plans
To prevent billing mistakes and problems in regard to incident-to services, physician practices should develop specific policies and procedures for coding and billing and make them part of their yearly compliance plans. Although the incident-to billing requirements appear to be simple and easy, there’s an increase in federal and state healthcare regulatory agencies tasked with overseeing the Medicare programs involving allegations of improper billing for incident-to services.
