Billing incident to is a question I frequently find in my inbox, on listserves, social media groups and at conferences. I’ve even seen this discussed, often erroneously on medical billing and coding discussion groups and listserves.

In most situations, this applies to  Medicare, but it is possible that your state Medicaid payer, as well as some commercial insurers have adopted, or will adopt these rules.

So what’s the deal about incident to?  Many practices that employee advanced practice clinicians (NPs and PAs) like to bill incident to. Why? Billing incident to allows a practice to collect 100% of the Medicare physician allowable reimbursement. As you know, advanced practice clinicians (NPs and Pas) are allowed only 85% of the physician allowable. Since profit margins are low, it makes sense that a practice wants to collect 100%.

Of course, it makes sense for clinicians to be paid for the same work…but that’s another story for another time.)

However, there are several rules which must be met when billing under incident to. It is your responsibility to understand the billing that takes place in your name. Ignorance is not a defense should the office be investigated for billing fraud.

Here’s a run down on the incident to requirements (references at the end of this article):

1. The Advanced Practice Clinician must be employed by or contracted to the physician or physician group.
2. The physician must see the patient first, establish the diagnosis and the treatment plan and remain actively involved in the patients care.
3. The services must be an integral part of the patient’s normal course of treatment, and are generally included in the physician’s bill.
4. The APC is follow up on the established treatment plan and is NOT addressing any new problems.
5. The physician must be immediately available and in the suite at the time the APC is seeing the patient to follow up on the previously established plan.

There are several problems here for any APC. The most common is the fact that when we are seeing patients, there is almost always something new to be discussed. A visit is rarely just about the hypertension and the medication that the physician prescribed. A new problem that must be addressed negates the visit as being incident to.

For those of us that are practice owners, it is highly unlikely there is a physician on the premises and we are not employed or contracted to a physician or physician group and a physician has not seen the patient first to establish the diagnosis and treatment plan.

As you can see, meeting the incident to rules is something that does not happen in our day to day clinical lives, regardless of who we work for and how we practice. It’s imperative that we understand and adhere to these rules, and that we educate those we work with.  If your practice is billing incident to, you’ll want to proceed with extreme caution. Being associated with healthcare billing fraud is something you want to avoid…like the plague.

You can learn more about the Medicare incident to rules as well as brush up on health care fraud at the sites listed below

• MLN Matters Number: SE0441 http://www.cms.gov/mlnmattersarticles/downloads/SE0441.pdf
• Medicare Information for Advanced Practice Nurses and Physician Assistants http://www.cms.gov/MLNProducts/downloads/Medicare_Information_for_APNs_and_PAs_Booklet_ICN901623.pdf
• Stop Medicare Fraud:  http://www.stopmedicarefraud.gov/
• Office of the Inspector General:  http://oig.hhs.gov/

(c) Barbara C. Phillips, NP, All Rights Reserved

Nurse Practitioners and other clinicians should be aware of the changes  that are taking place when it comes to diagnostic coding.

On October 1, 2013, medical coding in U.S. health care settings will change from ICD-9-CM to ICD-10. The transition will require business and systems changes throughout the health care industry. Everyone who is covered by the Health Insurance Portability and Accountability Act (HIPAA) must make the transition, not just those who submit Medicare or Medicaid claims. The compliance dates are firm.

If you are not ready, your claims will not be paid. Preparing now can help you avoid potential reimbursement issues in the future. Ask your clearinghouse, billing service or software vendor what you need to do to be ready for ICD-10.

To learn more, visit http://www.cms.gov/ICD10/. Start now.

Our next interview will be with Mylikia Ross, CMBS. Ms. Ross is the NPBO Billing Expert. She’s going to talk with us about finding that perfect biller and just what to expect from them! In addition to answering your questions, she has prepared some questions that you can use when you interview as well.

If you have already signed up for these updates, you?ll recieve the information to access the call either via phone or via webcast. If you have not signed up, please do so now at www.NPInterviews.com.

I’ve been getting lots of questions about coding for House Calls, and what codes to use.   Here are the current codes that are listed for house calls as well as codes used for assisted living. For the exact details of what is included with each code, please check your CPT manual.

You will need to visit your Medicare provider in order to get the current rates from Medicare. If you are unsure who is your intermediary, check your copy of the Nurse Practitioner Business Resource Directory. I have included a full list of providers from around the US. It was current as of the publication date.

Welcome to 2008! It’s already been a busy time. If you have not already done so, make sure you evaluate your fee schedules. There are new CPT codes and new reimbursements in place or will be put in place shortly.

While the intended Medicare 10% cut has not yet happened, the new rates are only good until June. Watch for impending changes…they may not be good for those of us who see lots of Medicare folks as 10% can be a huge cut in reimbursement.

At the same time, I noticed that Medicaid has cut its reimbursement and many of the commercial carriers are holding steady with last years rates.

Unlike business owners in other lines of work, health care providers, at least for now, seem to be at the mercy of the insurance carriers. While we can negotiate fees with carriers, it appears it will be a battle. I’m going to be working on one carrier shortly….I’ll let you know what happens. In the meantime to learn more, Medical Economics has published an article tis month: You Can Negotiate with Health Plans.

We get asked a lot about vaccines in the office. I’ve often held off doing them – one of my concners has been that reimbursement from certain carriers does not cover my cost to purchase the vaccine.

For the most part, the influenza vaccine has not been a problem. Last year, I only purchased a few to see how it would go. This year…we’ve held one flu clinic, and I’m still giving vaccines daily. I’ll probably hold one or two additional “clinics” before the season is over.

AAFP has published an article on how to code for these vaccines so you will not loose revenue. Timely I’d say.

 Coding Flu Shots: Immunize Against Lost Revenue

Every year, there are changes in the ICD-9 codes as well as the CPT codes.  Changes for the ICD-9 codes are effective 10/1/07. It’s important to be aware code changes - it will affect your reimbursement. If you don’t code correctly…you will not be paid.

Annually, the American Academy of Family Physicians publishes new coding tools in the Family Practice Management toobox. I keep a copy of the tool in each exam room and in my small coding book (along with my commonly used cpt codes and reimbursement – more on that later) at my desk. I use this, along with the Flash Code program daily.

Here is the article that discusesses the changes taking place –> ICD-9 Changes: New Codes of Note

It’s imperative that you have the correct coding resources available to you. It does not matter if you hire someone to code for you, or if you do it all yourself. You need the learn how to code (something that got left out of my program). It directly affects your bottom line.

So where can you learn this mysterious art? There are lots of resources available to you on line, books, forums and email lists just devoted to coding and billing.

If you are in a specialty area, often times, the professional associations will publish for their members, codes that are specific to that area of practice. For those of you in general practice|primary care|family practice, here are some resources for you.

Family Practice Management – They have loads of resources for your office. Templates for documentation, coding resources, and much more. Every year they publish a short and long list of ICD-9 codes that are most commonly used in Family Practice. Even though I have lots of stuff on my PDA, I keep a copy of this list in each exam room….and I use them.

Medical Economics Magazine – When you go to their site, you’ll find all sorts of information on practice management, coding and daily operations.

I don’t own this book, yet…but I’ve been hearing lots of positive things about it. It’s written by a physician who has been struggling just like the rest of us to get paid. I understand it’s very practical, full of examples and tips to make sure you are coding correctly. Not an easy task these days…I can tell you.

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Physicians Practice – Another website that is geared toward office operations with a bit of clinical information thrown in. Again, good information.

Coding911 – If you can get past the bright colors and busy website, you can find all sorts of good information. Several of the mailing list around coding comes from here…I belong to one, and it’s an excellent source of information.

Modern Medicine – A new site with a coding section. You will have to register, but it’s free.

Flash Code – This is one of my favorites. It’s a yearly subscription, plus with their special you get the books. I like it, as Ican log in and search for any code I want – ICD9, CPT, HCPCS, J-Codes, etc. To me, much faster than searching a book. And since our workstations all have computers with internet access, everyone can have access.