Coding Institute: Qualified NPPs can treat certain patients

Watch out for these pitfalls – and opportunities – of getting your NPPs to work for you. 

Having a non-physician practitioner (NPP) around can have its advantages as your practice can serve more patients and allow physicians more time to look at more complex cases; thus boosting revenue in the process. However if you don’t follow correct guidelines, you could fall prey to scrutiny from OIG and payers. 

In a Coding Institute sponsored audio conference “2014 Risk Areas for NPPs and Incident-To”, Elin Baklid-Kunz, MBA, CHC, CPC, CCS, said, “Under incident-to rules, qualified NPPs can treat certain patients and still bill the visit under the physician’s National Provider Number (NPI), bringing in 100 percent of the assigned fee.” The reimbursement equals the payment that the payer would have allowed had the physician performed the procedure. To qualify for incident-to, the visit must meet these criteria laid down by CMS:

• The NPP performs the service in a physician’s office and not in hospitals – inpatient, outpatient or emergency services. He must also have a direct financial expense relationship with the physician.
• The NPP performs the service within the scope of her practice and in accordance with State law. In the 2014 Medicare Physician Fee Schedule, CMS changed its incident-to regulations to directly require that personnel performing “incident-to” services meet any appropriate state law requirements to provide the services (and that includes licensure).

Note: There may be more audits for incident-to where the focus may be more on the registered nurse/LPN to see if the work that they are doing incident-to a physician is within the scope of what they are allowed to provide to Medicare patients.

• Thirdly, the physician must have seen the Medicare patient during a previous visit and established a clear plan of care. If the NPP is treating a new problem for the patient, or if the physician has not established a care plan for the patient, then you should refrain from reporting the visit incident to.

Note: However in many cases, even if you find the service doesn’t meet incident-to-billing requirements, you don’t have to miss out on payment totally. If a Medicare credentialed NPP provides the service, you can bill under his own NPI.

• Lastly, the physician must be on site (direct supervision) when the NPP is rendering the service. Direct supervision means a supervising physician must be immediately available in the office during the service. He may not be the physician who started the treatment. Make sure you bill in the name of the physician present and providing the supervision at the time of the NPP visit, irrespective of whether he saw the patient or not.

Note: See to it that the billing reflects this difference. The physician who supervises in the office goes in box 33 while the physician who wrote the plan of care for the visit goes in 17 of CMS Form 1500. Remember: Do not bill for the service if a member of your auxiliary staff such as a medical assistant provides a service when there is no direct supervision.