Despite advances in medication that have reduced occurrences of sexually transmitted infections (STIs) like HIV, other STIs are increasing. The CDC recently reported that chlamydia, gonorrhea, and syphilis reached an all-time high of 2.3 million in 2017 and emergency departments saw a 39 percent rise in STIs.
	
	While the causes of this increase are multi-factorial, some experts say that one of the most influential factors is that primary care physicians are not routinizing sexual health discussions as part of general health screenings.
	
	Veronica Whitehead, M.Ed, director of programs at the North Texas Alliance to Reduce Unintended Pregnancy in Teens (NTARUPT), based in Dallas says, “We have found that physicians don’t talk about sexually transmitted infections until there is an infection.”
	
	There may be a variety of reasons why physicians are not comfortable discussing sexual health, ranging from personal discomfort to the frequency with which they see their patients.
	
	“If the physician isn’t comfortable with talking about sex, they probably are not emphasizing it in talking with the patients,” says Michael Horberg, MD, FACP, FIDSA and executive director of research, community benefit and Medicaid for the Mid-Atlantic Permanente Medical Group in Washington, D.C.
	
	Victoria Mobley, MD, MPH, North Carolina Department of Health and Human Services, HIV/STD medical director and adjunct assistant professor in epidemiology at UNC Gillings School of Global Public Health suggests another cause of the rise in STIs may be that physicians stick too closely to traditional screenings-urine, vagina, cervix, and urethra.
	
	“We know that sexual experiences are much broader than that,” Mobley says, “People have oral sex, people have anal sex, including a good portion of heterosexuals.”
	
	She points out that a urine-only screening will miss more than 50 percent of infections in individuals who have exposures in other sites.
	“We have to be culturally competent in how we’re asking the questions about exposure and where we’re screening based on those answers,” Mobley explains.
	
	There may come a time when more people can take advantage of newly available home STI testing kits, which can be taken in a private setting and then shared with a doctor via mail or a follow-up appointment, But for now, the best method is to go to a physician. These kits are still relatively new and do not screen for all STIs.
	
	Mobley says the opioid epidemic, which is linked to risky sexual practices, including the exchange of sex for drugs or other goods or services, may also be contributing to the rise in STIs. “In some places in the country, they’ve seen quite a significant increase in STIs associated with drug use, particularly meth use.”


	
	The key to better screening, Mobley says, is making it routine to stave off some of the discomfort of this personal dialogue.
	
	“Every primary care provider should have a sexual health history as a part of every visit,” Mobley says. “If you do it for every patient, whether it’s a 22-year-old sexually active young man or a 54-year-old sexually active married woman, you ask the same questions, so they come to expect it.”
	
	For physicians who aren’t comfortable discussing sexual health right away, Ada Stewart, MD, a family practice physician with the Eau Claire Cooperative Health Center in Columbia, S.C., recommends making it part of written questions for the patient to fill out before the visit.
	
	Once a year, Stewart asks her patients to answer written questions about sensitive issues such as smoking, alcohol, drug use, and sexual issues. “Make it simple and as easy as possible so that you’re not overwhelmed and your patients don’t feel you’re rushing them through a visit.”
	
	Most important, she says, is developing a relationship of trust so the patients feel that they can talk about these issues. “It’s all about making patients feel comfortable with you and the care you’re going to provide them.”
	
	Horberg says that a sexual health screening need not be convoluted or invasive. He suggests beginning with two very simple questions, which are recommended by the CDC-supported Health Care Action Group, “Have you been sexually active in the past year?” And “Have you been sexually active with men, women, or both?”
	
	Asking the second question in particular can help determine which testing is needed. The CDC report found that the rise of syphilis was especially high in populations where men have sex primarily with men.  While no single population should be named as the culprit, Horberg emphasizes, it is important to note that as sexual relations with types and numbers of partners increase, so potentially do STIs.
	
	“We also know there are a lot of people who have sex with multiple sexual partners, both same sex and heterosexual sex, so if one population has an increase, it’s eventually going to spread to the other population,” Horberg says.
	
	Horberg acknowledges that medical schools don’t do a good job of teaching physicians to be comfortable discussing sexual health.
	“We forget sometimes that physicians come in with all of their anxieties,” Horberg says. “We try to leave them all at the patient’s door but sometimes it is hard to do. And it takes practice. Good sexual history like any other part of exam, it’s an art, something you have to practice,” Horberg says.
	
	He says that physicians should initially work from a script to reduce anxiety and standardize the process, which may make these conversations more natural over time. He also hopes that EHRs will eventually integrate sexual health screenings in a way that makes it easier for both physician and patient.
	
	Some resources for scripts include the AAFP’s article on “The Proactive Sexual Health History,” the National Coalition for Sexual Health’s guide, “Sexual Health and Your Patients: A Provider’s Guide,” and a guide by the American Sexual Health Association, “Sexual Health: Resources for Healthcare Providers.”


	
	Robert Segal, MD, a Manhattan-based cardiologist and founder of LabFinder, which offers home testing kits for a variety of medical issues, including some STIs, says it’s just as much a part of the physician’s role to educate patients as to screen them, as well as ask them more than routine questions, such as number of partners, and use of protection.
	
	“No matter our patient demographic, if they’re sexually active, we should be educating them not only on the importance of using protection, but on the fact that some STIs don’t always exhibit symptoms and the only way to know if you’re carrying a disease or infection is to get tested,” Segal says.
	
	This will be most effective, Segal says, when this is done with the intent to reduce a patient’s anxiety. “[Physicians] need to have an open and non-judgmental demeanor when inquiring about a person’s sexual history,” Segal says.
	
	Horberg also points out that patients need to know about the long-term effects of untreated STIs, which can lead to a variety of very significant health problems.
	
	“Even though many STIs are asymptomatic, the long-term effects of untreated STIs are legion,” Horberg says.
	
	While most physicians have a ways to go at becoming more comprehensive in helping patients prevent and treat STIs, the patient also has to play a role. Horberg says, “It’s important to mention that STI prevention is still also based on safer sex practices and rekindle those conversations.”


	
	Another likely cause of rising STIs is a vulnerable population: adolescents.
	
	“Young people feel indestructible. STIs are just not on their minds,” Mobley says.
	
	Physicians who see teens, whether pediatricians or family practice doctors, may not all be screening their patients for sexual activity or STIs for reasons that could range from personal discomfort to parents interfering.
	
	According to a 2015 article in JAMA Pediatrics, teens report low discussion rates around sexual issues during regular health visits and a reluctance to bring these issues up on their own.  One-third of all teen participants reported having regular health visits in which their physicians did not mention sexual issues at all.
	
	Mobley says this lack of discussion is especially concerning for teens, particularly girls. “A lot of these infections can be asymptomatic and if you don’t catch it in these young women, the consequences long term can be so severe.”
	
	Whitehead says that both physicians and parents need to work together to make sure these conversations, and when necessary, screenings, are taking place.
	
	She recommends that physicians start the conversation from a health perspective and make clear, “We’re not assuming anything about your child. We’re just sharing information.”
	
	Adolescents are hungry for this information, she says, because much of what they are getting non-medical sources, such as their peers or the internet, is incorrect. When her organization brings in a nurse practitioner to schools to discuss sexual health issues, she says: “The students just absorb it. The nurse practitioner will talk about anything from how STIs are transmitted to pap smears and breast exams. The students really appreciate that dialogue.”
	
	When it comes to discussing sexual health, she says: “Everybody is nervous. We have to put ourselves out there as the adults whether as a sex educator or as a physician.”

Articles

While the causes of this STI increase are multi-factorial, some experts say that one of the most influential factors is that primary care physicians are not routinizing sexual health discussions as part of general health screenings.

What should primary care physicians do about sexually transmitted infections?

Your last patient of the day, a 58-year-old woman with a history of type 2 diabetes and hypertension, opens her smartphone immediately upon entering the examining room. You are still clicking through the electronic health record (EHR), looking for her vital signs and information from your last visit, when she tells you she’d like to show you the apps that track her blood glucose levels, diet, and daily step count.
	
	And, by the way, her son recently told her about some other apps that could track her blood pressure as well as monitor when she takes her medication. Should she download them? Is there a way to get you the data? 
	
	Patients today are collecting and curating a phenomenal amount of health-related data-some useful, but most not. Many patients have some kind of smartphone or device in their pocket for most of the day that can provide real-time information about aspects of his or her health status. In addition, the technology market is quickly growing in this area, with new state-of-the-art medical devices, apps, and other programs, offering individuals the ability to monitor everything from glucose levels to UVA exposure to medication adherence.
	
	Bharat Rao, Ph.D., a data and analytics leader for KPMG’s Healthcare and Life Science Practice, a global professional services firm, says the combination of market forces, healthcare regulation and consumerism-plus the proliferation of data and the rise of cheap computing-has led us to this point.
	
	“There are all of these devices that have the potential to provide useful patient data, particularly for patients who have chronic medical conditions,” he says. “But there’s a lot of data out there. Probably too much data, in some senses. So while there is likely to be a few nuggets of value in all that information, the potential distraction in trying to deal with it all is so large that many wonder if it’s worth it.”
	
	If doctors can get the right kind of data at the right time, the information collected from these wearable devices may offer a strong potential for more accurate diagnoses, more personalized treatments, and better outcomes. The question remains, however, how can physicians get and manage the flow of all this new data to actually improve patient care?


	
	Ida Sim, MD, Ph.D., a primary care physician and director of digital health for general internal medicine at the University of California, San Francisco, says while many in the healthcare and technology sectors herald real-time collection and monitoring of patient data as a way of transforming patient care, this new data, in and of itself, isn’t as valuable as some might think.
	
	“In some ways, this new sensor data isn’t any different than the electrocardiogram data or CT scan data we already collect,” she says. “If you told a doctor, ‘We can run chemistry and liver panels on your patients every day for the rest of their lives and send that to you if you want,’ they would look at you like you are crazy.”
	
	“You need to take the same attitude with this kind of wearable data as you do with any other type of patient data and ask yourself why you asked for this data and what you can actually do with it,” she adds.
	
	Jim Weinstein, DO, MS, the head of innovation and health equity at Microsoft Healthcare, the arm of the technology giant dedicated to innovative healthcare solutions, agrees. But he says several studies show that today’s new wearable data can be quite valuable. While President and Chief Executive Officer (CEO) of Dartmouth-Hitchcock Health, an academic health system in New Hampshire, Weinstein spearheaded a pilot project called IMAGINECARE that used 24/7 patient monitoring through smart phone sensors and Microsoft tools to improve the health of employees who had three or more chronic health conditions.
	
	“Most patients see their doctor intermittently, at best. We now have the ability to monitor many of these diagnostic tests remotely,” he says. When IMAGINECARE did so, they were able to help 50 percent of those participating in the pilot get their blood pressure under control within a few months. Furthermore, 96 percent of the participants said they liked the program-and the health system projected their cost savings to approximately $250 per employee per month.
	
	Weinstein says he and his team were very pleased with the results. And while many physicians were wary of the IMAGINECARE program initially-as well as other programs in the health system that utilized patient monitoring data-Weinstein says providers eventually became “believers,” seeing benefits in having access to such data.
	
	“We can’t develop and or expect new devices and systems to be used and adopted if the doctor and or their patients don’t see the added value. Whatever we bring forward must improve care and lower the friction of delivering that care,” he explains. “We have optimism that these kinds of opportunities will grow in the future.”
	
	But Rao says while there is vast opportunity, with many use cases suggesting an important role for such data in the improvement of healthcare, there is also uncertainty. Healthcare information technology partners will have to think long and hard about how to present this data to both patients and physicians so that it is both meaningful and actionable. With so many physicians already frustrated with their interactions with EHR systems, adding more data to the pile without proper support is simply unsustainable. Dealing with such a data deluge cannot be done without technological assistance.
	
	“There need to be algorithms, machine learning programs, that will take all this data, make sense of it, and then present the valuable nuggets of information to the physician in a way that fits in with their workflow,” Rao says.
	
	Eric Rock, CEO of Vivify Health, a company that offers a remote patient monitoring platform, agreed. While it would be easy to say that one could simply port data from wearable devices into the EHR, it’s just not that simple. Physicians need a tool set that can take data and bring meaning to it so it can add value for both doctors and patients.
	
	“You just can’t dump enormous amounts of biometric data from smart devices into the EHR,” he says. “It will just be a complete failure and doctors won’t use it.”
	
	Sim says that with so many devices and apps already available to consumers, healthcare has “opened the firehose and doesn’t know what to do about all the water that’s spewing out.”
	
	“This isn’t something that can be dealt with by an individual practitioner,” she says. “We are struggling at the front end because this data comes in so many different formats-a .pdf file here, a [step tracker] read-out here, a blood glucose app output there. It’s all in different formats from different vendors, which leads to a lot of cognitive overload for providers.”


	
	Certainly, many technology companies are attempting to provide the kind of tools and platforms to relieve such cognitive overload. But Sim says that there is still a lot of work to do to understand how monitoring patient data can improve patient care. That said, she believes that until more of the uncertainty is resolved, physicians can use patient monitoring data to improve patient engagement and, in doing so, improve patient self-management and compliance.
	
	“We can use this information to find ways to provide our patients the feedback and interactions that they want-and I believe, as a physician, they deserve,” she says. She suggests that practitioners discuss with patients what kind of data they are collecting, why they are collecting it, and what they hope to do with it.
	
	Based on an individual patient’s specific medical needs and interest in wearable devices, providers can help curate what information is coming in from patients, separating the proverbial wheat from the chaff.
	
	“You can discuss the different devices and apps that may be available with your patients and make decisions together about what makes sense,” she says. “When you discuss with them what kind of data they could be tracking, either to share with you or to use for their own self-management, you have an opportunity to explain what these data points mean and where they can be helpful.”
	
	One can also, she adds, tell patients what data is not helpful.
	
	“Sometimes, patients will say, ‘Oh, I want to collect this information,’ and, frankly, it just isn’t that useful,” she says. “I just say they can go ahead and do it for their own needs if you want and tell me how it goes. Candid discussions about what kind of data is helpful is just not something we do right now-and we are going to have to start doing it.”  Weinstein added that wearable data not only can help patients with chronic diseases manage their day-to-day care-but this data may also provide an opportunity for doctors to prevent patients from developing chronic medical issues.
	
	“Prevention has been underutilized and is an important part of our future success in healthcare,” he explains. “Diet, exercise, and socioeconomic indicators have been woefully underappreciated when, in fact, they are some of the best predictors of outcome and health in various population segments.”
	
	Devices or apps that can collect this kind of data-and more-are likely on the horizon. And Weinstein says the same algorithms that will help make sense of wearable data can incorporate these kinds of social determinants of health data, too. In doing so, he believes such technologies will ultimately help to bring greater health equity to different populations within the United States.
	
	Rao says that wearable data is here to stay-and the amount is only going to grow. But Weinstein says that if the data can be seamlessly pulled from multiple technology sources and platforms, presented in a digestible format that makes sense to physicians, and delivered at the point of care, the benefits will quickly add up.
	
	“Physicians are generally resistant to things that could potentially harm their patients or interfere with their ability to care for them,” he says. “Therefore, any strategy involving this kind of data needs to involve the health system, doctors, nurses, other providers, staff and the patients themselves as we move forward. These technologies should be augmentative, to enhance the incredible efforts of physicians and nurses who dedicate their lives to those most in need. That is a marriage worth pursuing.”

If doctors can get the right kind of data at the right time, the information collected from these wearable devices may offer a strong potential for more accurate diagnoses, more personalized treatments, and better outcomes. The question remains, however, how can physicians get and manage the flow of all this new data to actually improve patient care?

How physicians can get useable data from wearables

It’s every physician’s worst nightmare: Receive payment for services rendered, but then a payer identifies an aberrant pattern in claims data, audits the records, decides it has overpaid the practice, and recoups those funds. That money you already allocated for overhead, staff salaries, bonuses, or new medical equipment? Gone. With one post-payment audit, you now owe thousands of dollars or more. The good news is, physicians can take steps to focus on accurate billing and avoid costly recoupments. This article explores five billing vulnerabilities
	and provides tips to maintain compliance.

E/M coding: Four tips to select the correct level

Payers don’t usually deny evaluation and management (E/M) codes on the front end, says Toni Elhoms, CCS, CPC, a provider coding and education consultant in Denver. It isn’t until they look at the totality of the data retrospectively-long after physicians are paid-that financial penalties ensue, she adds.

“Payers are like the IRS,” says Elhoms. “You don’t want them on your back because recoupments are insidious. They come out of nowhere.”
	Consider the difference in reimbursement for established patient office visits levels 2 versus 3 (i.e., CPT codes 99212 and 99213)-approximately $29. Let’s say 10 to 20 times per week over a year, a physician bills 99213 when their documentation only supports 99212. They’ll be paid initially, but likely have a $15,000-$30,000 recoupment on their hands if a payer uncovers the error during a post-payment audit.
	
	Here are four tips to help physicians avoid denials due to incorrect E/M levels:


	the specific patient encounter.
	Not every patient with asthma, for example, will justify reporting CPT code 99213, says Elhoms. Some cases may be exacerbated and/or require medication management and referrals to specialists while others may be relatively straightforward and controlled.


	Assigning an E/M code is not a subjective process. Instead, physicians should refer to the 1995 or ‘97 E/M guidelines that include specific requirements for time-based billing as well as billing based on the three key components: history, exam, and medical decision-making, says Elhoms. She says the most common mistake physicians make when applying these guidelines is under-documenting E/M level 4 and 5 visits for new patients. More specifically, they omit one or more systems in the requisite general multi-system exam or they omit a complete past family and social history.


	functionality with caution.
	Copy and paste can save time, but it can also cause serious compliance problems, says Elhoms. That’s because when physicians automatically bring historical information from a previous encounter forward into their current note, they may inadvertently inflate the E/M level. Best practice is to validate any information copied forward to ensure it’s accurate and relevant to the current encounter-or turn off the functionality altogether, she adds.

4. Watch out for pre-populated EHR templates.


	Pre-populated templates not only lead to upcoding (e.g., if certain body systems are always indicated as having been reviewed even when they’re not relevant to the current encounter), they can also lead to contradictions that raise red flags with payers, says Elhoms. For example, a physician diagnoses a patient with strep throat. If the template defaults to a normal exam for ear, nose, and throat, this could open the door for a post-payment audit. Physicians should ensure their documentation is aligned with the patient’s diagnosis even if it means manually unchecking certain boxes in the template.

Time-based billing for E/M services is appropriate only when the physician meets face-to-face with the patient and/or family and spends more than 50 percent of the encounter counseling and/or coordinating care, says Elhoms. It’s not appropriate when the counseling and/or coordination of care is rendered over the phone or via email, she adds. To avoid denials, consider these tips:

1. Know how much time is typically associated with each E/M level as well as  the amount of time a physician must spend counseling and/or coordinating care to bill solely based on time rather than the three key components (i.e., history, exam, and medical decision-making).
	Consider doing the following:

2. Document the total time spent face-to-face with the patient as well as the total time spent counseling and/or coordinating care.

3. Explain what the counseling and/or coordination of care entailed (e.g., answered questions regarding the treatment plan or extensively discussed treatment options.) Note that counseling and coordination of care does not include administrative tasks such as documenting in the EHR, dictating, refilling prescriptions, completing workers’ compensation applications, communicating with other professionals, or reviewing records and tests before or after the face-to-face visit.
	
	When physicians report prolonged services (i.e., CPT codes 99354 [first hour of the prolonged service] and 99355 [each additional 30 minutes]), they signal to payers that they spent face-to-face time above and beyond what’s typically associated with an evaluation and management service. CPT code 99354 yields approximately $132, and CPT code 99355 yields approximately $101.
	
	Physicians frequently provide prolonged services for new patients who are medically complex as well as established patients presenting with new and complex problems, says Sonal Patel, CPMA, CPC, a healthcare coder and compliance consultant with Nexsen Pruet LLC, a business law firm in Charleston, S.C.
	
	“Internists are the first line of defense for some of these patients, and they can easily talk for two hours, for example, with a patient who has diabetes before they refer them out to a specialist,” she adds. The same is true for patients requiring a cardiology workup.
	
	It’s important to document why this additional time was necessary, says Patel. More specifically, documentation should include the following:

Start and end times of the face-to-face prolonged service

Specifically what was discussed with the patient during the additional time

Patel provides these three additional tips for reporting prolonged services correctly:

1. Always report a prolonged service code with an E/M code. Prolonged services cannot be billed alone because they are ‘add-on’ codes.

2. Know how much time is required before billing a prolonged service is permitted. Consider the following:

3. Use the EHR to help calculate time spent on the prolonged service. Some EHRs enable physicians to use a timer when documenting, making it easier to track how much time was spent on the prolonged service and whether that service is separately billable.

Modifiers -25, -26, and -59: Expert advice to mitigate risk

When appended to a CPT code, modifiers provide additional information about how payers should reimburse certain services. Consider the following:

Physicians need to ensure they send the right message to payers so that message doesn’t come back to haunt them in the form of a recoupment, says Joette Derricks, healthcare compliance and revenue integrity consultant in Baltimore. “Many commercial payers have also tightened their reimbursement edits to deny modifier -25 claims upfront,” she says. It’s important to check with each payer to determine whether it has published any guidance before establishing a policy within the practice for reporting modifiers, she adds.
	
	Dorothy Steed, CCS, CDIP, a revenue cycle consultant in Atlanta agrees. “A lack of knowledge doesn’t typically work well as a defense,” says Steed, adding that physicians should study these modifiers and, if financially feasible, hire a certified coder to validate claims before submission. “If physicians don’t protect their financial resources, they’ll be in trouble and possibly out of business,” she adds.
	Consider the following tips to help  maintain compliance:
	
	 


	Apply this modifier to the E/M code-not the code for the procedure.
	
	Document why the additional E/M service was necessary and why it went above and beyond what’s typically required for the procedure. For example, a patient falls and suffers a laceration that requires stitches. If deemed necessary, the physician may perform a workup to determine whether the patient suffered a concussion during the fall. The physician could report a separate E/M service with modifier -25 for the workup if they document why they felt the patient was at risk for a concussion and what the workup entailed. The same is true for an annual wellness visit and separate problem (e.g., heart arrhythmia) that requires additional cardiology workup.
	
	Use this modifier with caution when performing pre-scheduled and/or repetitive procedures (e.g. skin tag removals or pain injections). The E/M service associated with these procedures (e.g. checking the patient’s heart, lungs, and blood pressure) is not usually significant and separately identifiable. Other services may be separately billable, depending on the circumstances.


	Apply this modifier to a global procedure code (i.e., one that includes the interpretation and test itself) when a more specific code is unavailable. For example, apply modifier -26 to CPT code 71045 (single-view chest x-ray) when the physician performs the interpretation only. If the physician owns the equipment and performs the test, modifier -26 isn’t necessary, and reporting it can actually result in an underpayment.
	
	Know when a more specific code is available. Consider this scenario: A physician performs the interpretation and report of a routine electrocardiogram (EKG), but doesn’t perform the tracing. In this case, report CPT code 93010 (interpretation and report only)-not CPT 93000 (EKG with tracing, interpretation, and report) with modifier -26.
	
	Ensure compliance when using an outsource coding vendor. Derricks says she provided consulting services to an internal medicine practice that owed several thousand dollars back to the payer because its coding vendor failed to apply modifier -26. The vendor wrongly assumed the physician performed various radiology procedures in addition to the interpretation, resulting in a significant overpayment.
	 


	Only apply this modifier when appropriate to non-E/M codes with a Correct Coding Modifier Indicator of ‘1’ (modifier allowed). To view modifier indicators for each code, visit https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html. Most practice management systems also include this information.
	
	Think of this modifier as a ‘last resort.’  If another modifier is more appropriate, use that modifier instead. Consider these other options first: -RT (right), -LT (left), or -50 (bilateral procedure). Payers may also accept modifiers -XE (separate encounter), -XS (separate organ or structure), -XU (unusual non-overlapping service), or -XP (separate practitioner).
	
	Know the criteria. Medicare recently published Medlearn Matters article SE1418 that includes clinical scenarios and guidelines for proper use of modifier -59.

Incident-to billing: Know the requirements to ­ensure compliance

Incident-to billing enables non-physician providers to bill services under a supervising physician’s National Provider Identifier (NPI) rather than their own NPI so the practice can collect 100 percent of the Medicare physician fee schedule amount, rather than 85 percent. However, incident-to billing has several requirements that, if unmet, can cause costly recoupments during post-payment audits, says Jamie Claypool, CPC, CPMA, practice management consultant at J. Claypool Associates Inc. in Spicewood, Texas.

Following are several common reasons for denials and how to avoid them:

Reason for denial: Incident-to services are billed for a new patient visit.

How to avoid it: Schedule all new patients with a physician who can establish a plan of care. Then schedule all follow-up appointments for the same problem with the non-physician provider, and bill those appointments incident-to the physician, says Joette Derricks, healthcare compliance and revenue integrity consultant in Baltimore.

Reason for denial: Incident-to services are billed for an established patient with a new problem.

How to avoid it: Ask the supervising physician to talk briefly with the patient and establish a plan of care for the new problem. The physician must then document their assessment of the problem, including any relevant history, exam, and medication decision-making as well as the plan of care itself. If a physician isn’t available to do this, bill the visit under the non-physician provider’s NPI, assuming they are credentialed with the payer, says Derricks.

Reason for denial: Incident-to services for new problems do not meet supervision  requirements.

How to avoid it: Ensure a supervising physician is always in the office suite and immediately available. Note that the supervising physician doesn’t need to be the same person who established the initial care plan, says Claypool. It simply needs to be a physician employed by the practice, she adds.
	
	Payers will go so far as to request access to daily schedules to determine whether the physician under whom the incident-to service was billed was in the office and immediately available (e.g., whether they too saw patients in the office during the same timeframes), says Claypool.
	
	Nursing home visits can be tricky. If the non-physician provider sees patients in a nursing home, they can’t bill incident-to a physician unless that physician has an office in the nursing home, sees patients in that office, and is immediately available, says Derricks. A non-physician provider could also bill incident-to if the physician is in the room during the visit, but this doesn’t happen often because it’s counterproductive to tie up both providers with the same patient, she adds.

Reason for denial: Commercial payer requires -SA modifier to denote incident-to services. 

How to avoid it: Know whether the payer requires it and for what types of providers, says Derricks. For example, some Medicaid programs such as California Medi-Cal and Texas BCBS require physicians to apply modifier -SA to all nurse practitioner services submitted under the physician’s NPI. Texas also requires it for physician assistants, and Tufts health plan in Massachusetts requires it only for nurse practitioners.

It’s every physician’s worst nightmare: Receive payment for services rendered, but then a payer identifies an aberrant pattern in claims data, audits the records, decides it has overpaid the practice, and recoups those funds. That money you already allocated for overhead, staff salaries, bonuses, or new medical equipment? Gone. The good news is, physicians can take steps to focus on accurate billing and avoid costly recoupments. 

August 10, 2019 Edition

What should primary care physicians do about sexually transmitted infections?

How physicians can get useable data from wearables

Boost revenue by getting coding right

Medical Economics cartoon: What to do in case of burnout?