There does seem to be confusion among some physicians and their professional clinical staff when it comes to correctly billing for “incident to” services at 100 percent of the physician’s fee schedule. The Medicare Carrier’s Manual defines “incident to” as follows: “services furnished as an integral although incidental part of a physician’s personal professional services.” This recognizes the valuable role physician assistants (PAs) and nurse practitioners (NP) play in the healthcare industry and in the care of patients.

It is recommended that PAs and NPs conscientiously comply with Medicare’s guidelines in billing for services that fall under the “incident to” category in order to ensure proper reimbursement and to avoid audits. For a service to be considered as an “incident to” service, it must meet the following criteria.

• The service performed must be one that is typically performed in a physician’s office.
• The service performed should be within the scope of practice of the PA or NP.
• The physician should be in the office or office suite (on-site) when the service is rendered.
• The physician must personally treat the patient on the patient’s first visit to the practice or treat established patients who come to the office with a new medical condition.

To illustrate the difference between an “incident to” service and one that does not meet the criteria, here are two examples.

Example 1: A 70-year-old Medicare patient has been treated previously by the physician and was diagnosed with rheumatoid arthritis. The patient comes back to the physician’s office a month later with some pain in her joints. The PA or NP sees the patient and subsequently reviews the patient’s medical history and current medication(s). He or she also discusses current pain levels with the patient. The PA or NP then performs a level two exam, noting any changes from the previous exam. Finally, the PA or NP prescribes some medication for the pain. The Medicare beneficiary leaves the office without seeing or having direct contact with the physician on this visit. However, the physician was in the suite of offices when the PA or NP treated the patient.

This is an example of an “incident to” service that would be reimbursed at 100 percent of the physician’s fee schedule. In order to receive 100 percent reimbursement, Medicare requires that the claim form on an “incident to” service be filled out with the physician’s name and provider number.

Example 2: A PA or NP sees a 70-year-old Medicare patient, who comes into the office for a follow-up visit for her rheumatoid arthritis. She previously saw the physician for this problem. During the follow-up visit, the PA or NP diagnoses pharyngitis and prescribes an antibiotic.

This is an example of a service that would be reimbursed at 85 percent of the Medicare Fee Schedule. The visit starts out as “incident to” service but when the PA or NP starts treatment on a new problem, it stops being an “incident to” service. The PA or NP must bill for the visit under his or her own number unless the physician sees the patient, examines her and documents it.

Key Points In Billing For ‘Incident To’ Services
For those PA and NPs that work in group practices, there might be some difficulty in determining which physician is the supervising physician for “incident to” services. CMS has recently clarified that the supervising physician does not have to be the same physician who first established the patient’s plan of care. Therefore, if you work in a group practice, a method for choosing which doctor to list as the supervising physician must be established. It might be wise for the doctors to designate a particular physician as the supervisor for all “incident to” services on certain days and then rotate each day.

Other Essential Coding Tips

- Here are some additional coding tips to help minimize denials and increase your reimbursement accuracy for all types of patient encounters. • Always document how much time you spend with patients. This includes the time you spend reviewing patient records and tests. When you spend more than 50 percent of your time face-to-face with the patient, this time may be a key factor to justify for the billing of a higher E/M level. • Make sure you include all diagnoses that are present in the patient’s chart and on the CMS 1500 form to meet the level of services you bill. • Make sure your UPIN number is in box 25 on the CMS 1500 form. • Always remember the motto: “If it is not documented, it did not happen and it is not billable.”

For billing, you should list the ordering physician’s name in Box 17 on the CMS 1500 form and his or her UPIN in Box 17A. The supervising physician’s UPIN goes in Box 24k, and his or her signature goes in Box 31. Finally, the practice or group’s UPIN will go in Box 33. To ensure fair physician payment, you should base compensation on the physician listed in Box 17, not Box 24k or 33.

Generally, private insurance companies present a different problem for coverage of medical services provided by the PA or NP. Most private insurers require that the bill for services provided by the PA or NP be filed under the physician’s name and provider number. It is recommended that the PA or NP periodically verify with the individual insurance company’s provider relations department for specific policies on coverage for services provided by a PA or NP.

What You Should Know About Billing For E/M Visits
Physician assistants and nurse practitioners are held to the same coding and billing guidelines as physicians. Documentation is the key element for achieving appropriate reimbursement, particularly when it comes to evaluation and management (E/M) visits. For example, you likely spend a considerable amount of time with rheumatoid arthritis patients and documentation is your best defense for your level of E/M coding.

E/M services are made up of seven components. In coding your level of patient care, the three key components of E/M visits are history, examination and medical decision-making. The other four components (counseling, coordination of care, nature of presenting problems and time) are considered contributory factors.

Documentation of the three key components is an important part of each patient’s record. Understanding the guidelines for these components is critical in properly billing for services rendered.

There are four types of history for present illness (HPI): problem focused, expanded problem focus, detailed and comprehensive. A brief history consists of one to three elements and an extended history consists of four or more elements. In order to support your level of care, keep in mind that the HPI includes the following elements.

• Location. Determine where the pain is located (i.e., localized, lateral, unilateral or bilateral).
• Quality. Be sure to note a description of the pain (i.e., sharp, dull, throbbing or constant).
• Severity. Describe the level of pain (i.e. use a scale of 1 to 10).
• Duration and timing. Ask the patient when the pain began and how long he or she has had the pain. Was it nocturnal pain? Was the pain diurnal or continuous?
• Context. Determine what the patient was doing when the symptoms began. Was he or she resting, active or working?
• Modifying factors. Has the patient done anything to alleviate the pain? For example, has the patient tried over-the-counter drugs or natural remedies?
• Associated signs. Note any associated signs such as nausea or sweating.

Table 1.

The examination or review of systems (ROS) is an inventory of the body systems. A problem pertinent ROS is directly related to the problem(s) one identifies in the HPI. An extended ROS is directly related to the problem(s) one identifies in the HPI and a limited number of additional systems. A complete ROS involves the system(s) directly related to the problem(s) one identifies in the HPI plus all additional body systems.

The following systems are recognized as a guide to support your level of examination.

Constitutional. This is a review that covers any unusual symptoms (i.e. night sweats or fatigue).

Eyes. Identify the date of the last eye examination (i.e., glaucoma).

Ears, nose, throat and mouth. Note the last hearing test and any history of nose bleeds or sore throat. Also note the patient’s last dental checkup.

Cardiovascular. Ask if there are any chest pains, palpitations, hypertension or murmurs.

Gastrointestinal. Inquire about problems with indigestion, burning sensation or reflux.

Genitourinary. Inquire about changes in urinary frequency patterns (i.e., painful urination or incontinence).

Integumentary. Note scarring, swelling, moles or lesions (i.e., pain or itching).

Musculoskeletal. Inquire if there is any joint swelling, stiffness or problems walking or exercising.

Endocrine. Ask the patient if he or she has thyroid disease, diabetes, unexplained weight loss or an increase in thirst.

Hematological or lymphatic. Inquire about problems with anemia, energy level and/or blood transfusions.

Allergic or immunological. Ask the patient if he or she has a history of allergies or frequent sneezing and itching.

Psychiatric. Inquire about a history of psychiatric treatment or conditions.

Where Medical Decision-Making Comes Into Play With E/M Visits
The final component in an E/M visit is the medical decision making. Medical decision making defines the steps a physician will take to treat the patient. Before the PA or NP can determine the extent or level of the decision-making process, one must answer three questions:

• How many diagnoses pertain to the visit?
• How many tests have been ordered (i.e. labs or x-rays)?
• What is the patient’s risk for disease?

Additionally, the PA or NP should always ask if there are any contributing factors that could affect treatment.
One should utilize the following four levels of medical decision-making.

Straightforward. This involves a minimal number of diagnoses, reviewed data and risk of complication(s).

Low complexity. This involves a limited number of diagnoses, reviewed data and a low risk of complication(s).

Moderate complexity. This involves a multiple number of diagnoses, a moderate review of data and a moderate risk of complication(s).

High complexity. This involves an extensive number of diagnoses, an extensive review of data and a high risk of complication(s).

To qualify for a certain type of decision-making, it is necessary to meet two out of the three elements in the decision-making criteria noted in the above table “A Guide To Medical Decision-Making For E/M Visits.”.

Chung

Collins

Final Notes
Documentation is a vital part of your billing and reimbursement process. Everyone should know that even the smallest detail(s) can make a big difference in your claims processing. To consistently achieve appropriate reimbursement levels with a minimal number of denied claims or audits, checking for all the necessary, important details is the best strategy.

Ms. Chung and Ms. Collins are employed as reimbursement specialists by the American College of Rheumatology in Atlanta. They are certified as professional coders by the American Association of Professional Coders. For more information, please contact them at (404) 633-3777.