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Incident-To billing clarification: A physician as an extender


Clarification on an incident-to billing question: Will Medicare allow a physician to render a service incident-to another physician?

Q:Will Medicare allow a physician to render a service incident-to another physician?

A: We received a number of questions about our Coding Insights column published in our August 10, 2015, issue, particularly about this sentence:  “Health and Human Services has recently clarified that a physician can function as an extender under the direct supervision of another physician. As a result, it would be permissible to report services performed by a non-credentialed physician under the name of a credentialed physician when all the incident-to requirements have been met.”

The Centers for Medicare & Medicaid Services (CMS) has verified that a physician can bill for incident-to services rendered by another physician as long as all incident-to criteria is met. Medicare’s incident-to requirements are primarily contained in the Code of Federal Regulations (CFR) 410.26 and in CMS Medicare Benefit Policy Manual, Chapter 15, Section 60.

Since this information was quite different than how we’d been taught, we followed up with our local Medicare carrier and received clarification that this was being done in part because the Medicare enrollment was behind and they didn’t want to preclude physicians from working while they wait for their enrollment to be finalized.

However, I want to reiterate that I don’t believe this is the best practice-and that this only applies to Medicare, not any other payer.

Q:What constitutes a new problem for a patient when billing incident-to? Is it any new problem requiring a change to the original MD treatment plan?

A: According to Medicare’s MLN Matters Number SE0441, “To qualify as ‘incident-to,’ services must be part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment.”  That means that a physician has to have personally evaluated the patient and determined the plan of care, which would then be followed by the nurse practitioner (NP) during subsequent visits.

Therefore, to answer your additional questions, any change in the treatment plan would need to be determined by the physician in order to be followed by the NP.  Wisconsin Physician Services, our regional Medicare carrier, has clarified that a new plan of treatment change would need to be determined again by the physician in order for subsequent visits to be billed incident-to. In other words, the specific plan of care for a situation would need to be instituted by the physician in order for an NP to follow.


NEXT: Billing external codes in ICD-10


Q:Are we supposed to bill external cause codes in ICD-10?  Are we allowed to bill unspecified codes?

A: MLN Matters® Number SE1518 specifies the use of external cause and unspecified codes in ICD-10-CM.

Here are some points to consider:

External cause code reporting

MLN Matters® Number SE1518 states that there is no national requirement for mandatory ICD-10-CM external cause code reporting.  This is similar to ICD-9-CM coding.  

The only exceptions to this are if you are subject to a state-based mandate for external cause reporting or a particular payer requires these codes to be billed.  Outside a state or payer requirement, you are not required to report ICD-10-CM codes found in Chapter 20, External Causes of Morbidity, of the ICD-10-CM codebook.  

However, you are encouraged to voluntarily report external cause codes, because they provide valuable data for injury research and evaluation of injury prevention strategies.  Also, submitting this information could cut down on questions from your payers, who are trying to determine whether or not a workers’ compensation payer would be liable for the cost of the services rendered.

Unspecified code reporting

In both ICD-9-CM and ICD-10-CM, sign/symptom and unspecified codes have acceptable, even necessary, uses. While you should report specific diagnosis codes when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, in some instances signs/symptoms or unspecified codes are the best choice to accurately reflect the health care encounter. You should code each health care encounter to the level of certainty known for that encounter.

If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s). When sufficient clinical information is not known for a particular health condition to be able to assign a more specific code, it is acceptable to report the appropriate unspecified code (i.e., a diagnosis of pneumonia has been determined but the specific type has not been determined).

In fact, you should report unspecified codes when they most accurately reflect what is known about the patient’s condition at the time of that particular encounter. It is inappropriate to select a specific code that is not supported by the medical record documentation or to conduct medically unnecessary diagnostic testing to determine a more specific code.

All the Medicare claims audit programs will use the same approach under ICD-10 as are used under ICD-9. All providers are expected to code correctly and document to support the code(s) selected. For example, if a physician is treating a patient for diabetes, there should be an ICD-10 code on the claim for diabetes. The level of specificity of the diabetes code selected will not change the coverage and payment of services in most cases.

Q:How are home health claims going to be paid when the stay spanned before and after October 1?

A: Medicare recently reported that ICD-10-CM codes are required on Home Health claims with a THROUGH date on or after October 1, 2015.

Since Home Health claims are submitted for a 60-day payment episode, there may be cases where an episode spans October 1. In these cases, the Requests for Anticipated Payment (RAPs) for an episode will be submitted using ICD-9 codes and the corresponding claim will be submitted using ICD-10 codes. Medicare does not require ICD-10 coding of these episodes in advance of the ICD-10 implementation date. Home Health Agencies should determine whether identifying the ICD-10 codes in advance will benefit them.

Answers to readers' questions were provided by Renee Dowling, a billing and coding consultant with VEI Consulting in Indianapolis, Indiana. Send your billing and coding questions to medec@advanstar.com.

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