Master Core Curriculum

Master Core Curriculum Part B Intermediate Module 3 Incident To

Learning Outcomes At the end of this module, participants will be able to: • define the Incident to Provision • describe billing requirements for services provided by ancillary personnel • correctly bill for services provided by Non-physician Practitioners such as Physician Assistants (PAs), and Nurse Practitioners (NPs) • describe the differences between locum tenens and reciprocal billing

Definition of ‘Incident to’ Services and Supplies • Services or supplies that are an integral, though incidental, part of the physician’s or non-physician practitioner’s professional services • Services or supplies that are part of the patient’s course of treatment • Services or supplies that are commonly rendered without charge • Services or supplies commonly furnished in a physician’s office or clinic • Services or supplies that are an expense to the physician or non-physician practitioner

“Incident to” Supplies • Supplies commonly furnished to perform the professional service • Examples include gauze, ointments, bandages, and oxygen • Are an expense to the physician • Charge is included in the charge for the physician’s professional service

Drugs Covered as “Incident to” • In order to meet all the general requirements for coverage under the incident-to provision, an FDA approved drug or biological must: • Be of a form that is not usually self-administered; • Must be furnished by a physician; and • Must be administered by the physician, or by auxiliary personnel employed by the physician and under the physician’s personal supervision.

Direct Physician Supervision • Direct physician supervision of auxiliary personnel is required • Auxiliary personnel – any individual (employee, leased employee, or independent contractor) • Auxiliary personnel include nurses, medical assistants, technicians, etc. • Supervising physician must have a valid reassignment agreement with the billing entity.

Physician’s Professional Service • A direct, personal, professional service by the physician is required • Physician must initiate the course of treatment • Subsequent physician services to show ongoing involvement

Examples of “Incident to” Services • Taking blood pressure • Giving injections • Changing dressings • Taking height and weight

Direct Supervision in the Office • Physician must be present in the office suite • Physician must be immediately available • Does not require that the physician be in the same room

Incident to Services in a Group or Physician-directed Clinic • Generally, the same “incident to” rules apply • Direct supervision may be responsibility of several physicians • Ordering physician (attending physician) need not be the supervising physician • Services performed outside the group/clinic premises must be performed under the direct supervision of a group/clinic physician.

Documentation of “Incident to” Office Services • Who performed the Incident to service • The physician’s presence in the office suite during the service/procedure

Settings Outside the Office • Services in beneficiary's home require direct physician supervision • Services in an institution, such as nursing home, require direct physician supervision • ‘Incident to” services in hospital or SNF are not covered by Part B • Remember, direct supervision requires that the physician be immediately available to render assistance if that becomes necessary.

Physician’s Office Within An Institution • Must be a separately identifiable part of the facility • Must be used solely as the physician’s office • Cannot be construed to extend throughout the institution • Services “commonly furnished in physicians’ offices” • Auxiliary personnel must be members of office staff • Physician must have performed a personal professional service

Scenario: Injection by Nurse in Patient’s Home • Accompanying physician on house calls, injection is covered • Nurse made the call alone, injection is not covered • Physician must be present to provide direct supervision

Certain Services for Homebound Patients “Incident to”, Under General Supervision • Medically underserved areas when no home health agency serves the area • Homebound patients • Personnel (nurse, technician, physician extender) meet State requirements • Patient is being treated by the physician • Physician orders the service and provides general supervision • Physician is not physically present in the patient’s home; provides overall supervision and control • All other “incident to” requirements apply

Covered Services Under General Supervision for Homebound • If no HHAs available, certain services may be covered under general supervision by the physician. • Injections,venipuncture; EKGs; therapeutic exercises; catheter care; • Collection of specimens; dressing changes; nasogastric tubes, • Fecal impaction; paraffin bath therapy, and • Teaching and training the patient for specific medical needs

Non-physician Practitioner (NPP) Services Incident to Physician Services • Non-physician Practitioners may provide additional “incident to” services • Certified nurse midwives, clinical psychologists, clinical social workers, physician assistants, nurse practitioners, and clinical nurse specialists • Minor surgery, setting casts or simple fractures, reading x-rays, and other activities that involve evaluation or treatment of a patient’s condition. • All “incident to” guidelines apply

Evaluation & Management Services Furnished “Incident to” • Performed by an NPP Incident to a physician’s service, physician may bill the appropriate level E/M code. • If “incident to” guidelines are not met, the claim is filed using the NPP’s PIN • Performed by non-physician employee of the physician (nurse, medical assistant, etc.) and not part of a physician service, physician bills CPT code 99211 for the service.

“Incident to” Services - Claim Filing Requirements • Example: Dr. Green evaluates and treats Mrs. Smith for hypertension. She returns in two weeks and Nurse Brown takes her blood pressure. Dr. Green is not in the office but Dr. Black, his partner, is. • Name/UPIN of physician who performed the initial service and ordered the non-physician service in Items 17 and 17a or equivalent electronic field (Dr. Green’s name and UPIN) • PIN of the supervising physician in Item 24k (Dr. Black’s PIN) • Services are billed and paid as though the supervising physician personally performed them

NPP Services When “Incident To” Requirements Are Not Met • NPPs may perform services within their scope of practice based on licensure or state law in any setting without physician supervision • Services and procedures NPPs may perform • If medically necessary, the services are covered by Medicare • Report the NPP’s PIN in Item 24k or equivalent electronic field • Services are allowed at 85% of the physician fee schedule amount

“Incident to” Rules Do Not Apply • Flu Shots • EKGs • Laboratory tests • X-rays • Each service has its own statutory benefit category and rules

Reciprocal Billing Definition • Services performed by a substitute physician may be billed and paid to the regular physician • Regular physician arranges for the substitute to provide the services • Substitute physician provides the services on an occasional reciprocal basis • Specific requirements must be met

Reciprocal Billing Requirements • Regular physician is unavailable • Patient asks to receive services from the regular physician • Substitute services for a continuous period of no more than 60 days • Regular physician bills with modifier “Q5” and his/her own PIN • Regular physician records each service with substitute physician’s UPIN

Medical Group Claims Under Reciprocal Billing • Does not apply among physicians of the same group, except for hospice attending physician designation • Requirements apply if substitute physician is from outside the group

Locum Tenens Arrangements • Substitute physician when regular physician is absent • Absence for illness, pregnancy, vacations, continuing education, etc. • Regular physician bills and receives payment as though he/she performed services • Substitute physician doesn’t have a practice; moves around as needed • Regular physician generally pays substitute a fixed per diem amount

Locum Tenens Billing Guidelines • Regular physician is unavailable • Beneficiary asks to receive services from the regular physician • Substitute services for a continuous period of no more than 60 days • Regular physician bills with modifier “Q6” and his/her own PIN • Regular physician records each service with substitute physician’s UPIN • Note: If the physician is deceased, neither locum tenens nor reciprocal billing provisions apply. No services may be billed under the deceased physician’s PIN.

Medical Group Claims Under Locum Tenens • Group paying locum tenens is deemed payment by absent physician • May use (only for up to 60 days) for physician who has left the group • All locum tenens billing and documentation requirements apply

Chapter Review Slide • Review question 1: What is meant by “direct supervision” for Incident to office services? • Review question 2: In addition to direct supervision, what other involvement does the physician have to have to file claims for Incident to services?

Chapter Review Slide • Review question 3: How should you file claims for services performed in the office by a nurse practitioner while the physician is making hospital rounds? • Review question 4: How should you file the claim for a service when the patient’s regular attending physician who is a member of the group is not in the office on the day when the patient returns to have a recheck of his bronchitis and is seen by the nurse practitioner?

Chapter Review Slide • Review question 5: What type of claim filing arrangement is used by Dr. Smith while he is on vacation and Dr. Jones who has a solo practice in the medical building next door agrees to see his patients and allow Dr. Smith to file claims for the services? What modifier is used?

Chapter References/Citations • CMS Online Manual System, Pub. 100-2, Medicare Benefit Policy Manual, Chapter 15, Sections 60 and 160-210. • CMS Online Manual System, Pub. 100-4, Medicare Claims Processing Manual, Chapter 26, Section 10.4. • CMS Online Manual System, Pub. 100-3, National Coverage Determinations Manual, Section 70.3.

Chapter References/Citations • Medlearn Matters Article MM3138, “Incident to Services” • Medlearn Matters Article SE0441, “Incident to Services” • CMS Online Manual System, Pub.100-4, Medicare Claims Processing Manual, Chapter 1, Sections 30.2.10-30.2.11.

Master Core Curriculum