Updated on: November 29, -0001

Top 10 Federal Audit Findings for Incident-to Services in Physician Practices Part I

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Original story posted on: June 1, 2016

A well-established patient, Mrs. Brown, calls your office in the morning for an urgent “fit in” appointment. Since the four practice physicians are either fully booked or not in the office today, she will need to be seen by one of the nonphysician practitioners. Well-known to all of the providers, she has been steadily followed for diabetes mellitus and hypertension. Today she has called to be evaluated for new onset high grade fever, lassitude, and generalized joint pain. She’s also mentioned to the receptionist that her antihypertensive medication may not be working as well as she hoped since her last visit five (5) months ago.

Q: Is this a valid incident-to scenario that can be handled, documented, and billed by your office Physician Assistants or Nurse Practitioners? 

Incident-to services are fast becoming the standard operating policy of numerous physician practices—both independent and healthcare network-owned—from burgeoning pediatric and primary care offices to busy surgical practices of all clinical specialties, including orthopedics, obstetrics, and cardiology subspecialties such as electrophysiology (EP) testing. In fact, in many physician practices incident-to revenue generated by nonphysician practitioners (“NPPs,” e.g., physician assistants, nurse practitioners, and clinical nurse specialists) has materialized as a fiscal staple, its capture now paramount to business success. Naturally, this increase in incident-to service frequency is paralleled by an increase in payer billing. For governmental payers, particularly Medicare and Medicaid, these services have proven to be “low-hanging fruit” for federal auditing entities. Many physician practices are vulnerable to such investigations. 

The scope of practice and tenets of incident-to billing can get confusing, even for well-seasoned practice staff. Office services, inpatient facility services, outpatient facility visits: which in this mix are valid under incident-to? High-frequency services (e.g., “Coumadin clinic”), preventive visits, annual wellness care: Are all these types of services billable as incident-to? New patients, established patients, and well-known patients with new problems: Can all of these patient classifications be managed by NPPs under incident-to, under “split/shared,” or both, in order to carry a fair share of the daily patient load? How do you legitimately accomplish that? 

Identifying and following the Centers for Medicare and Medicaid Services (CMS) guidelines for incident-to services is not as easy as following GPS directions! The medical record (MR) documentation necessary to support such services is quite specific, and can vary between Medicare Administrative Contractors (MACs). While the general rules are supposed to be the same across the board, it’s proven the baseline criteria might be more restrictively enforced by one MAC over another. Adhering to the various rules can be tedious, but once the basic principles are uncovered and the federal target areas are known, physicians and NPPs can navigate these minefields with aplomb and leverage the increasingly important NPP services to maximum benefit.      

In the face of increasing heat from various federal auditing entities, I will cover—in an info-packed webcast July 14, 2016—the serpentine rules and regulations that underpin incident-to services. I will also include the ostensible disparities between the MACs as I address the top 10 hot areas targeted by federal auditors for incident-to services billed by physician practices. Additionally, if you tune into the Monitor Mondays radio program Monday, June 13, 2016, I will answer the Q: scenario posed at the start of this column which I will also address in Part 2 of this article]. Tune in to find out more. 

About the Author 

Michael G. Calahan, PA, MBA, is the vice president of hospital and physician compliance for HealthCare Consulting Solutions (HCS). Michael lives and works in the Washington, D.C. metropolitan area, specializing in federal compliance and facility inpatient/outpatient and physician activities.

Contact the Author 

mcalahan@hcsglobal.net or mikiecal@hotmail.com

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Michael Calahan, PA, MBA, AHIMA-Approved ICD-10 CM/PCS Trainer

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