If your practice utilizes Advanced Practice Providers (APPs), such as nurse practitioners or physician assistants, and you’re billing for their services as incident to under the physician, consider having a focused external chart audit. We often find that practices bill services using this method; however, they don’t always understand the guidelines they must meet to do so compliantly.
Incident to is a CMS provision that allows billing office-based APP services under the physician’s National Provider Identifier (NPI) and receiving 100% reimbursement rather than the 85% rate if the APP billed under their own billing number. The higher level of reimbursement makes it easy to understand why a practice would bill as such; however, there are very clear and specific requirements associated with this method and if they’re not followed precisely, these claims may be in violation of the False Claims Act (FCA).
In a recent Office of Inspector General (OIG) enforcement action, a Lansing, Michigan area health system agreed to paying more than $671K to settle allegations related to improperly billing for services rendered by APPs without meeting the incident to requirements.
To qualify as incident to documentation must support the following:
- The service provided was integral, although incidental, and part of the patient’s normal course of treatment based on the physician’s initial service and treatment plan. Documentation must support that the physician remains actively involved in the patient’s treatment.
- A new patient or a new problem for an established patient does not qualify for billing as “incident to” since the physician must perform the initial service for a new patient or for a new problem.
- All practitioners involved must be actively employed by the same entity either as an employee, a leased employee, or they may be an independent contractor.
- Services are performed and billed in the office setting, using place of service (POS) 11, for physician’s office.
- Physicians are expected to demonstrate involvement in the patient’s treatment by performing subsequent services at a frequency that reflects participation during treatment for the specific “established” problem or problems. An example used to describe this frequency by Novitas Solutions, a Medicare Administrative Contractor (MAC) for Washington, DC, Delaware, Maryland, New Jersey, and Pennsylvania, indicates that “a patient with chronic sinusitis will probably not have to be seen by the physician as often as a patient with congestive heart failure.”
- Medical records for the patient should support that the physician is seeing the patient frequently enough to demonstrate their involvement in caring for the condition or conditions for which they have established the treatment plan(s).
- Incident to services are performed under direct supervision, which is defined as the physician present in the office suite, immediately available and able to aid and direct throughout the time the service is performed. The supervising physician does not have to be in the same room, but must be in the office or clinic.
- If the entity providing patient care is a group practice, it’s acceptable for another physician of the group to be in the suite and available for oversight should the need arise. Group members may “cross cover” for each other and still meet the incident to guidelines.
In conclusion, if your practice bills as incident to, contact The Rybar Group to discuss how we can help your organization understand the associated risks, ensure that you’re consistently following the guidelines, and provide practice-specific training related to billing using this method.