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Understanding Incident-to Billing: Dermatology Practice Insights

By May 14, 2024No Comments

What is Incident to Billing?

Incident-to billing allows non-physician providers (NPP), such as Nurse Practitioners and Physician Assistants, to render follow-up services to patients under the direct supervision of a physician.  The direct supervision means that the physician provider must physically in the office.  There are some exceptions, which will be discussed below.  The incident to services are billed under the physician’s NPI number and will be paid at 100% of the physician fee schedule, just as if the physician/provider was personally providing the service.  The importance of “Incident to” billing in dermatology cannot be understated as it significantly increases practice revenues and allows the practice to provide dermatologic services to a larger number of patients.

Incident-to Billing Guidelines and Requirements

The NPP cannot see new patients or an established patient with a new problem.

  1. The NPP must be an employee of the supervising physician’s practice
  2. The physician must see the new patient or new problem first, establish a care plan, and remain active in the patient’s care plan.
  3. The NPP must be under the direct supervision of a qualified physician.
  4. The NPP must be credentialed with Medicare.

Supervision by a Qualified Provider

NPPs providing incident-to services must be under the direct supervision of a qualified Provider.  However, the Pre-Covid Public Health Emergency, (PHE) implemented waivers that allowed direct supervision to be provided via audio/visual technology.  This waiver has been extended until December 31, 2024.

Benefits of Using NPPs

With the continued shortage of physicians in our country, the increased use of NPPs is inevitable.   Once you are fortunate enough to find a quality NPP, it is important that the practice owners make the most out of having these additional providers.   Utilizing them as frequently as possible, especially under the incident-to billing, becomes an excellent option for increasing the volume of patients seen.

A significant advantage of incident-to billing is that services rendered by the NPPs can be reimbursed at 100% of the physician’s fee schedule, a higher rate compared to the typical 80 or 85% when the NPP submits claims under their own NPI number.  This type of billing, simplifies billing processes, maximizes NPP utilization, and boosts reimbursement rates for their services.

Compliance and Regulatory Considerations for Incident-to Billing

It is vital to follow the Medicare incident-to guidelines carefully in order to prevent denials, recoupment, or allegations of fraud or abuse.   Be aware that not all payers follow Medicare’s incident-to guidelines or payment policies.  Cigna, for example, requires modifier SA on incident-to-claims and paid at the NPP rate (e.g., 80-85%).  Some carriers do not allow incident-to billing at all.   In such cases, the NPP must be credentialed and bill under their own NPI.   CMS (e.g., Medicare Administrative Carrier) may have different requirements.  It is also especially important to be aware of all your contracted carriers‘ incident-to policies before billing.

Lastly, be aware that Medicare and other federal health care agencies are making the audit of incident-to services a priority.  If the OIG (Office of the Inspector General), can prove that false claims were submitted with the knowledge of the providers in the practice, the results can be devastating.   Huge paybacks, fines, and other financial penalties, possible jail time, and/or the loss of the medical license for years or for sometimes forever are available options.   Most false claims act penalties are frequently in the millions of dollars.

Signature Requirements

The NPP is the rendering provider and documents the encounter.  The supervising physician is the billing provider.  Signature requirements for the supervising physician vary significantly by the payer as well so be sure that you follow their signature policies for both the supervising providers and the NPP.

Supervision Challenges

Keeping track of incident-to supervision can be a challenge.  It is considered a Federal False Claim to misrepresent the provider of services on a claim.  The office administrator or billing office manager should have a way to closely monitor which physicians are supervising which NPPs, on which day, at which office, and for which type of staff.   Keep in mind that PAs or NPs can also be supervising providers but, only if the services are billed under their own NPI number.

It is vital to not only keep track of the supervision nuances, but additionally you must also keep track of who were the ordering providers, if applicable. The ordering physician is the physician who initially saw the patient and developed the treatment plan.  The new requirements by Medicare are extremely strict regarding the identification of the ordering, referring versus the rendering, and supervising providers.

Incident-to Billing Examples

Meets Incident-to guidelines, bill under the supervising providers NPI:

  • A patient returns for wound check and suture removal with no global period in effect.
  • A patient returns for a follow-up visit for acne, the current treatment plan is showing improvement in the condition and nothing has changed.
  • A patient returns following a course of 5FU for field AKs on the face and scalp. The 5FU is effective and spots are healing.  Nothing has changed.

Does not meet Incident-to guidelines, bill under the NPP’s NPI:

  • A patient returns for a follow-up visit for acne. The treatment plan has been ineffective and the patient is continuing to have breakouts. NPP initiates Accutane.
  • A patient returns for treatment of AKs on the face. The NPP treats a few spots on the face and prescribes 5FU for newly diagnosed of AKs on the scalp.
  • A patient returns for suture removal on the arm and points out a new lesion on his face, which itches. NPP diagnosed an ISK and treats with LN2.

Per Medicare, a physician may supervise four NPPs. Commercial payers or State laws may differ. As the demand for healthcare services rises alongside the projected shortage of 81,180 full-time physicians by 2035, dermatologists are also turning to NPPs to expand their workforce and meet the growing needs of the population. Many states are consequently considering expanding the scope of practice for dermatologists and their NPP counterparts.

Telehealth Supervision Guidelines

Due to the Public Health Emergency legislation, which started in 2021, the Centers for Medicare & Medicaid Services (CMS) announced major expansions, (e.g., waivers) to existing telehealth policies. The goal, under Medicare, was to eliminate major regulatory barriers around telehealth and enable patients to communicate with their doctors remotely during this national emergency.

Telehealth services can be delivered with telephones that have audio and video capabilities.  HHS is waiving penalties for Health Insurance Portability and Accountability Act (HIPAA) violations against health care professionals that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype.  These waivers have been extended through December 2024.  CMS will also reimburse for audio-only telephone calls.  However, CPT codes 98966- 98968 and CPT codes 99441-99443 are not considered telehealth services and should not be used as there are separate codes for these services.

Check the following document to further your knowledge regarding the Telehealth Waivers.  The National Telehealth Policy Resource Center for Connected Health:  Billing for Telehealth Encounters and Introduction Guide for Fee-For-Service.   Also, checking the website of your local Medicare carrier is highly suggested.

In Summary

Utilizing the incident-to billing opportunities for your NPPs offers many practice advantages.  However, careful adherence to the existing billing guidelines for both Medicare and non-Medicare carriers is vital to avoid costly audits.

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