Incident To and Shared/Split Services - Effectively Billing for Non Physician Providers

June 17th, 2012

If you use NPPs (non-physician practitioners) in your practice, learn the rules for appropriate billing; or face possible recoupment or even false claim charges! 

Really, this is serious!

Misuse of “incident to” billing has been identified by auditors as a concern so many times, that scrutinizing the incident to services is AGAIN part of the HHS Office of Inspector General’s 2012 Work Plan.  “Incident to” was also scrutinized by the OIG in 2001, 2003, 2004, 2007, 2008 and 2009.

What Is “Incident To” and When Can You Bill It?

In a physician’s office, qualified NPPs can treat certain patients and still bill the visit under the physician's National Provider Identifier (NPI).  If billed under the physician’s NPI, the NPP is invisible and the practice will be paid physician rates instead of NPP rates which typically are fifteen percent (15%) lower.

CMS' Benefit Policy Manual defines "incident to" as "services furnished as an integral although incidental part of a physician's personal professional service."   To qualify as “incident to”

1. The NPP must perform the service in a physician's office (place of service 11).

2. The NPP must perform the service within the scope of the practice and in accordance with state law.  (Check your state board.)

3. The physician must establish the care plan for the new patient to the practice or any established patient with a new medical condition. NPPs may implement the established plan of care.  If the physician has not seen the new patient or evaluated the new condition, billing must be under the NPP’s NPI.  The physician must remain actively involved in the care of the patient.

4. The physician must be on site when the NPP is rendering the service.

You CANNOT bill Medicare for “incident to” in a hospital setting -- either outpatient, inpatient, or in the emergency department -- as incident-to. Medicare doesn't allow it.

For more information on “incident to” see:  the Medicare Claims Processing Manual (MCPM), Chapter 12, Section 30.6.1.B,  Medicare Benefit Policy Manual, Chapter 16, Section 60 and MLN Matters Number: SE044.

If Using a NPP in Hospital, Examine the Share/Split Rules

Although “incident to” is not allowed in facility settings, there are other rules that will allow a share/split of a visit between a physician and NPP.

When a physician provides services in the hospital, he may opt to share the work with a non-physician practitioner (NPP) to provide high quality services in minimal time. Not understanding these rules can cost a practice 15 percent every time he bills under a NPP instead of a physician.  . Make sure you're bringing in every dollar by learning these three split/shared visit guidelines.

Understand Shared Visit Rules

Split/shared rules come into play when one of your physicians and a qualified nonphysician practitioner (NPP), such as a nurse practitioner or physician assistant, each see a patient face to face in the hospital. Each provider performs a distinct part of an E/M service.

If the encounter meets shared visit guidelines, you may report the entire visit under your physician's National Provider Identifier (NPI) and be allowed 15 percent more for the same service.

As with incident-to services, a practice receives 100 percent of the Medicare allowable for the physician when services are reported under NPI. The same service under the NPP's NPI, will be allowed at 85 percent of the Medicare fee.

To bill a shared visit under the physician's NPI, a physician must provide and document a face-to-face service for the patient. The hospital records should include:

  • Documentation by the physician and the NPP of services supporting the E/M level billed.
  • A clear indication as to which services were provided by which provider (the NPP and physician.)
  • A reference in the physician's documentation that the NPP’s services were reviewed and approved noting any exceptions or additions to approval.
  • The physician's and NPP's documentation must indicate a face-to-face encounter with the same patient on the same day in the hospital
  • Legible (or approved electronic) signatures of the physician and NPP providing the E/M must be included.

The physician must ALWAYS perform and document at least part of the E/M visit in a facility setting.  Direct patient face-to-face contact is mandatory for shared services.

An example provided by Medicare of acceptable billing for a shared service is:

If the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service.

Split Billing Still an Option

In MLN Matters article SE1010, CMS notes that "the split/shared rules applying to E/M services remain in effect, including those cases where services would previously have been reported by CPT consultation codes."  In the past, you could not report the consultation codes as a split/shared visit as the physician alone could formulate the initial treatment plan.

You could, however, bill the codes now used for consultations (99221-99223 and 99231-99232) as a split/shared visit, allowing the physician full pay when he shared the work for this patient with an NPP. 

The best practice for hospital claims that would have been treated as consultation is the past, is for the physician to perform and document all elements of the E/M service because it is the expertise of the consultant that is sought by another provider.

Although CMS guidance does appear to allow split/shared billing for the codes now being used for consultation, the rules on split/shared E/Ms exclude consultations (and intensive care and procedures) from split/shared coverage.  Consultants were to evaluate all new patients and new problems. If, however, the consultant assumes part of the care for the patient, he is no longer acting as a consultant.  Thus, he may use NPPs under the splite/shared billing rule.

Per CMS Transmittal 1875:

A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer. The split/shared E/M visit applies only to selected E/M visits and settings (i.e., hospital inpatient, hospital outpatient, hospital observation, emergency department, hospital discharge, office and non facility clinic visits, and prolonged visits associated with these E/M visit codes). The split/shared E/M policy does not apply to consultation services, critical care services or procedures.

***

In summary, assuming the physician has assessed new patients and new problems, has remained involved in a patient’s care and has properly documented the services; a NPP’s services may be billed under the physician’s NPI:

In the office:  When the physician is on the premises at the same time.

In the hospital:  When the physician sees and is involved in patient care ON THE SAME DAY.  Exceptions:  consultations, critical care and procedures.

Please note the discussions above relate to Medicare rules. Be sure to check with your commercial carriers to see if they follow the same rules.

Tags: Incident to, Shared/Split Services

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