1. Understanding the Risk & Reward of Incident-to Diana R Phelps, CPC, CPC-I, CEMC Approved AAPC ICD-10-CM Instructor

2. Objectives Definitions of Types of Services Compliance Issues Non-Physician Providers (NPP) Direct Supervision Regulations Billing Options Billing Health Plans Conclusion

3. “Incident-to?”

4. Definitions Incident-to – Medicare regulation – Services or supplies are furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness. – Services are performed in the physician’s office or in the patient’s home. – Realize it is often used by private payers to mean something else Shared/Split – 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.

5. Compliance Issues Understand regulations – Medicare – CA Law Effective January 2016 - Senate Bill No. 337 – Medicaid/Medi-cal Programs – Different payers Communicating to physicians, NPPs, and billing staff Communicating to patients who the billing provider is OIG is interested in making certain that the incident-to rules are being followed

6. Non-Physician Providers (NPP) Two groups: – Physician Assistants (PA) – Advanced Practice Nurses(APN’s or ARPN’s) Nurse Practitioners (NP) Clinical Nurse Specialists (CNS) Certified Nurse Midwives (CNW) Certified Registered Nurse Assistant (CRNA) There are “other” groups, Physical Therapists Speech/Audiologists, etc.

7. Non-Physician Providers (NPP) Each state has regulations regarding the scope and level of supervision required for each type of practice. Must have a national certification/license Must have a state license/registration Must have a NPI # Employees of a physician or a physician directed clinic – W-2 employee or legal entity that employs the physician – 1099 contracted/leased employee – Under the control of the physician – Must present an expense to the physician, group practice, or legal entity

8. Direct Supervision is Required Incident-to coverage “is limited to situations in which there is direct physician supervision of auxiliary personnel”. Physician must be present in the office suite and immediately available to provide assistance and direction. – Provider supervising does not need to be the physician who performed the initial service. Should be billed under the supervising physician's name.

9. Incident-to Regulations Physician performs the initial visit (for that condition) and establishes the diagnosis and plan of care Physician must be in the office suite and immediately available NPP must be following a plan of care established by the physician Physician remains actively involved Service must be performed in the physician’s office by an employee (NPP) of the physician or physician’s directed clinic Service is within the NPP’s scope of practice and in accordance with state law Services must be those usually performed in the office

10. NPP’s Documentation Documentation to support the level and type of service being billed Document the supervising physician at the time of the visit Physician also sees the patient and/or participates in the MDM, that should be noted Physician reviews the chart, films, etc. with the NPP, that should be documented in the chart

11. Services Incident-to an NPP Services performed by auxiliary personnel supervised by NPP and following plan of care established by NPP – Can only bill lowest level of E/M service (99211) – Medicare will pay the claim at 100% of the physician fee schedule, even though the services were furnished by the auxiliary personnel (RN, Health Educator, Tech). Example: Patient in for a blood pressure check, dressing change, injection, etc.

12. Criteria for billing 99211 as “Incident-to” Must be an established patient There must be an established plan of care There must be an E/M service provided by an employee of the physician Must be provided in the office There must be direct physician supervision

13. NPP’s Billing Not “Incident-to” NPP can bill E/M levels 99211-99215 PA or NP can bill Medicare at the full physician rate for the following under their own NPI and receive 85% of the physician fee schedule amount. – Consults – New patients – New problems or changes to the treatment plan – Established patients

14. Billing to Medicare Incident-to – Bill under physician NPI and get paid 100% of Medicare fee schedule. Billing directly – Physicians (MD or DO)100% – Nurse Practitioners (NP) 85% – Clinical Nurse Specialist (CNS) 85% – Physician Assistants (PA) 85% – Certified Nurse Midwives (CNM)100% (as of 2011)

15. Shared/Split Billing Shared visits can be used when: – Both the NPP and the physician work for the same entity (i.e., same practice, same hospital, etc.) – Service performed was an E/M service and not a consult or a procedure – Physician provided face-to-face portion of the E/M service with the patient (did not simply review and agree with the NPP’s description on the patient’s chart) – Both the NPP and the physician see the patient on the same calendar day. If all criteria is met, then bill under the supervising physician’s Medicare number with payment at 100% of the fee schedule. If not met, then bill under the PA’s Medicare number with payment at 85% of the fee schedule.

16. Shared/Split Billing (cont.) Applies to only selected E/M visits and settings. – Hospital inpatient, hospital outpatient, observation, discharge – ER department – Office and non-facility clinic visits – Prolonged visits associated with these E/M visit codes Does not apply to: – Consultation services – Procedures – SNF/NF settings

17. Signature Requirements For Medicare, the MD/DO or NPP billing the service is not required to sign documentation prepared by the NPP or ancillary personnel – Signature of the person performing the service is required – Co-signing a note does not qualify the service as incident-to – Incident-to requirements for Medicare billing are separate and distinct from any facility or group rule requiring all services must be signed by the physician However, I did find per Noridian for CA -2013 this info: Ancillary staff note must be signed by supervising (billing) provider

18. CA LAW EFFECTIVE JAN. 2016 Senate Bill No. 337 Requires the medical record of each patient treated by physician assistant (PA) to identify the physician responsible for supervising Also, provides new mechanism for supervising physician to demonstrate adequate supervision of PA functions under protocols – Meet monthly, at least 10 months per year – Review at least 10 medical records of the PA – Physician and PA required to jointly sign and date documentation of the review meeting

19. CA LAW EFFECTIVE JAN. 2016 Finally, bill permits a supervision physician to review, countersign and date, within seven days, a sample consisting of the medical records of at least 20 percent of the patients cared for by the PA for whom the PA’s Schedule II drug order has been issued or carried out, if the PA documentation of the successful completion of an education course that covers controlled substances, and that controlled substance education course meets specified standards.

20. Billing Health Plans Incident-to can mean something completely different. – Some allow billing under the MD regardless of incident-to guidelines or physician presence. – Some credential separately and allow independent billing – Only certain CPT codes – Payment at 70-85% of physician fee schedule (varies by CPT) – Private payers will have their own guidelines or requirements.

21. Billing Health Plans (cont.) Suggestions and key questions to ask your carriers: Do you credential non-physician providers? Do you include them in your provider listing and allow patients to select them as primary care providers? Do you require that submitted claims use the NPP’s name and provider number, or the physician’s name and provider number? Do you require any specific level of supervision or protocol? If we bill for the services of the NPP using the physician’s provider number, and the patient’s usual physician is not in the office, should we bill under the usual physician’s name or the name of the physician who is in the office? What is the reimbursement rate for NPP services?

22. Incident-to for California Medi-cal PANP under supervising physician NP under own number Enrollment Requirements Must be enrolled with Medi-cal. Must be an expense to the physician practice. Must be enrolled with Medi- cal. Must be an expense to the physician practice Must be enrolled with Medi-cal and a certified CPNP or CFNP. Must be an expense to the physician practice. Types of servicesAny service within scope of practice that would be covered if performed by a physician. May only perform services listed in the manual (regardless of SAR/TAR approval. See Medi-cal NMP manual for details. Any services within scope of practice that would be covered if performed by a physician. ModifiersU7- to denote PA servicesSA- NP rendering service in collaboration with physician No special modifier Claims informationMost include provider name, number and type in box 19 Must include provider name, number and type in box 19 None Supervision Limitation Physician may supervise a max. of 4 NPPs at a time Same Reimbursement100% under their number or physician Same

23. California Medi-cal (cont.) Per California law, a supervising physician must countersign 5% of a physician assistant’s documentation within 30 days of the service. There is no countersignature requirements for NP’s. Each patient must be initially informed that he/she may be treated by a non-physician medical practitioner. NP’s must be enrolled with CDHS Provider Enrollment Services for Medi-cal reimbursement. CCS – follow the same rules as straight Medi-cal, except that NPs may not become individually paneled providers. Reference: – http://files.medi-cal.ca.gov/pubsdoco/publications/masters- mtp/part2/nonph_m00o0311.doc http://files.medi-cal.ca.gov/pubsdoco/publications/masters- mtp/part2/nonph_m00o0311.doc

24. Conclusion Incident-to services are office-based Shared/Split visits are mainly for hospitals NPP’s are very cost effective and accepted in just about every clinic – Less time spent waiting for physicians – Patient volume grows – 15 % payment is made up in some cases 4 tips for billing incident-to : – Physician must see patient first to determine treatment plan – Patient must be established, with an established problem – Services must be medically necessary and appropriate in the physician’s office – Direct supervision is required

25. Conclusion NPP’s can bill under their NPI number: – New patients – Established patients with new problems,treatment changes or a physician is not in the office – Consults CA LAW: – PA must document the supervising physician within the note – Recommend the NP do the same Medicare, Medicaid and commercial carriers can have different rules for incident-to and shared/split billing.

26. Five Key Steps 1.Professional service 2.Location 3.Employment relationship 4.Initial service was performed by physician 5.Supervision PLEIS Remember when you are working with “incident-to”

27. Physician’s waiting for Medicare Note: A new physician waiting for the 885 application for the Centers of Medicare and Medicaid Services (CMS) approval can use the incident-to billing BUT must be aware of the compliance risks and must strictly adhere to the rule’s requirements to avoid liability. Check out the AAPC’s Healthcare Business Monthly-January 2014 for a good article on the subject.

28. QUESTIONS ?

29. NOTE The key here is to realize that there is not a one-size-fit all model for reimbursement. It is essential that you know the specific billing rules for each payer in your market.

30. References https://med.noridianmedicare.com https://www.cms.gov/...SE0441 www.calhospital.org/find/results/SB%20337 http://www.wpsmedicare.com/ http://www.physicianspractice.com/blog/incident-to- billing-it-worth-it-medical-practices http://www.physicianspractice.com/blog/incident-to- billing-it-worth-it-medical-practices http://medicaleconomics.modernmedicine.com/medical- economics/content/tags/incident-billing-clearing-confusion http://medicaleconomics.modernmedicine.com/medical- economics/content/tags/incident-billing-clearing-confusion HCPro Incident-to and Shared/Split articles Internet Only Manual (IOM) – Publication 100-2, Chapter 15, Section 60.1 – Publication 100-04, Section 30.6.1