Incident-To Billing and Mid-Level Provider Coding in 2016

Coding and Billing: What Mid-level Medicare rules are on the horizon for 2016?

There’s a deeply troubling 14.6% error rate for E/M claims as of last year… and MLP claims are part of the problem. In most cases, the issue is overpayment, which means Medicare is demanding refunds of providers. It’s important to distinguish between E/M visits that can be billed under the physician’s NPI, those that must be billed under the MLP’s NPI, and those that are shared services. If the MLP sees an establish patient/established problem under the same overarching clinic, office, or suite as the patient’s physician, the E/M visit can be billed under the physician. Otherwise, bill under the MLP’s NPI, unless it’s a shared visit in the hospital setting. From an industry insider’s perspective, one of the most pressing questions is how to draw a distinction between incident-to billing, which is billed under a supervising physician’s NPI, and billing that should be done under a MLP’s NPI.

Incident-to: What does it mean? How do you decide when an encounter should be billed as incident-to?

An encounter between an MLP and a patient can be billed as incident-to and thereby be reimbursed 100% by CMS, if that encounter is for a medical problem considered “previously established” and where the patient has been seen by a physician in that practice for this previously established problem. The encounter can be billed as incident-to under the NPI of a physician in the same practice, even if that’s not the physician who initially saw the patient (see below.) If the encounter is billed under the MLP/NPP’s NPI, then it will be reimbursed 85%. It is therefore vitally important to sort out whether or not a problem is new or previously-established in a patient’s case history, when dealing with physicians and MLPs working together in practices. When a problem is previously-established, it should probably be billed as incident-to, under the physician’s NPI; but when a problem is new, something the patient hasn’t been seen for before, the NPP/MLP should bill under their own NPI for 85% reimbursement.

Changes to incident-to billing in 2016 mid-level Medicare rules?

Gladly, no! It was actually projected that a rule change would go into effect January of 2016 making it more difficult for MLP/NPP services to be billed as incident-to, but thanks to a reversal, incident-to rules are unchanged for 2016. It is still the case that you can bill under a physician’s NPI for an encounter when a MLP or NPP sees a patient as an encounter incident-to, so long as there is a physician in the office, and they are part of the same practice. Specifically, it’s been clarified that the physician does not need to be the same physician as in the patient’s previous encounters. This allows for much broader incident-to billing, and it means that CMS is allowing you to be fully reimbursed more often than expected.

Get the inside advantage and understand the ins and outs of the incident-to question, questions of CMS and supervision of NPP/MLPs in general, and all questions of mid-level Medicare rules with the expert advice of AAPC-certified CPC Barbara J. Cobuzzi in her talk on Coding and Billing for Mid-Level Providers.

Leave a Reply

Your email address will not be published. Required fields are marked *