A few weeks ago, in part 1 of this article, I sketched out a vignette that’s a fairly common occurrence in physician practices across the country. The vignette described an established patient scheduled to be seen by one of the practice non-physician practitioners (NPPs). Although well-known to the providers for chronic conditions such as diabetes mellitus and hypertension, she now presents with new onset complaints. She gives a current history of high fever, fatigue, and generalized joint pain. As an aside, she also mentions that her blood pressure medication doesn’t appear to be working.

Similar scenarios, tackled every day by medical offices treating Medicare beneficiaries, surface repeatedly on the federal list of “gotchas” by Medicare Administrative Contractor (MAC) and Comprehensive Error Rate Testing (CERT) auditing entities. So I asked our readers to weigh in: “Is this a valid ‘incident to’ scenario that can be handled, documented, and billed by your office Physician Assistants or Nurse Practitioners, or not?” The answer in this case happens to be “no,” but why? 

There’s a very restrictive framework of guidelines built by the Centers for Medicare and Medicaid Services (CMS) around reimbursement via ‘incident to’ reporting. Specific to the outlined scenario, I’ll steal my answer right from one of the larger MACs, Noridian Healthcare Solutions (a.k.a. Noridian Medicare), in its matrix of ‘incident to’ “dos and don’ts” (bolding mine):  

When “billing ‘incident to’ the physician, the physician must initiate treatment and see the patient at a frequency that reflects his/her active involvement in the patient’s case. This includes both new patients and established patients being seen for new problems. The claims are then billed under the physician’s NPI.”

So there you have it; Noridian Medicare sums it up pretty well. Of course, the NPP can evaluate and treat the patient in the above scenario and report the service under his/her own National Provider Identifier (NPI). When doing so, and not reporting a service under ‘incident to’ criteria, the visit is paid at 85 percent of the Medicare Physician Fee Schedule rate. 

That was a quick view into the oft-misunderstood rules wrapped tightly around ‘incident to’ services. But physician practices deal with much, much more. In designating or allocating patient visits between providers, physicians and their office administrators must wrestle with several factors. A core issue relevant to NPPs must always revolve around applying their healthcare practitioner skillset to best advantage. But what’s the optimal way to effectively empower your NPP’s healthcare provider expertise while still leveraging the NPP’s role as revenue generator? And how can achieving those goals be accomplished to the practice’s gain but still soundly within federal compliance?

Nowadays, federal healthcare dollars are guarded by a maze of sharp-edged compliance rules and regulations. While “it takes a village” to appropriately utilize and bill for NPPs in the office involving receptionists, coders/billers, and the practice administrator, it must start with the providers themselves. They must be responsible for knowing—to an operational degree—the CMS guidelines. Providers should know CMS guidelines? Yes, it’s critical that both the physicians as well as each practice NPP know the guidelines that allow the freedom to evaluate and treat Medicare patients, as well as get paid for services in numerous and ever-changing daily scenarios. 

Not to belabor the point, but this briar patch of rules and regulations ensnares many physician practices in its thorny tangle. Help is on its way. In my upcoming info-packed webinar (July 14), using a “top 10” easy-to-listen format, I’ll review a laundry list of ‘incident to’ facts and figures, dos and don’ts, traps, and pitfalls to keep your practice on the right side of the federal auditors. I will also cover how the ‘incident to’ paradigm relates to a wide range of services and NPP visit alternatives including split/shared visits, “regular” preventive medicine encounters, special benefit preventive medicine, and similar services such as Initial Preventive Physical Exams (IPPEs), better known as the “Welcome to Medicare” examination, Annual Wellness Visits (and Advance Care Planning), Transitional Care Management, Chronic Care Management, and Telemedicine opportunities—all service categories available to engage your NPPs! 

About the Author 

Michael G. Calahan, PA, MBA, is the vice president of hospital and physician compliance for HealthCare Consulting Solutions (HCS). Michael lives and works in the Washington, D.C. metropolitan area, specializing in federal compliance and facility inpatient/outpatient and physician activities.

Contact the Author 

mcalahan@hcsglobal.net or mikiecal@hotmail.com

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PROGRAM NOTE: Michael Calahan is scheduled to appear on Monitor Mondays, June 20, 10 a.m. ET to discuss “Incident-to” services.

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