Healthcare Advisor: Growth of Physician Extender/Mid-level Services Brings Proper Billing into the Spotlight

With the continued growth of the aging population in the country and with the implementation of the Affordable Care Act, medical practices and hospitals have experienced increased demand for healthcare services. This changing dynamic in the healthcare market has placed a premium on the available time for both primary care physicians and specialists. To address the growth in patient traffic, medical practices and hospitals have added physician extender positions to their organizations with increasing frequency.

By utilizing physician extenders, a practice can offer care to patients with less direct involvement from the physicians in the practice. The combination of physicians and physician extenders working together in a practice allows the practice to provide the needed care to patients on a daily basis. A physician extender is trained and state licensed to facilitate many of the medical activities which are typically performed by a physician. A physician extender is most commonly a nurse practitioner or physician assistant, but also includes certified clinical nurse specialists, certified midwives and clinical social workers. Medicare uses the term non-physician practitioner (NPP) to identify physician extenders.

The demand for physician extenders is projected to grow drastically in the next decade. There are two primary reasons for this. First, the baby boomer generation, with 10,000 people reaching retirement age each day, will continue to have increased healthcare needs as it ages. Second, the Affordable Care Act (ACA) has opened up access to healthcare services for millions of Americans who were previously uninsured or unable to afford needed care. According to a study conducted by the Bureau of Labor Statistics, the number of physician extenders is expected to grow by 38 percent during the 10-year period between 2012 and 2022. This trend line within the medical profession correlates with the growing number of baby boomers approaching retirement age.

Understanding Proper Billing Used With ‘Incident to’ Billings

While physician extenders are poised to play an increasingly important role in the patient growth strategy of medical practices, administrators responsible for overseeing the billing of office services involving physician extenders must follow insurance payer and state guidelines. “Incident to” is the Medicare billing policy that allows the physician extender to bill under the physician’s National Provider Identifier (NPI). Not all payers recognize “incident to” billing. Other payers, including each state’s Medicaid program, need to be contacted to determine if the payer recognizes “incident to” and what the guidelines are. Many times, this information may be found on the payers’ websites or in the provider manuals.

Why would a practice consider billing Medicare services as “incident to?” When physician extenders submit Medicare billing under their NPIs, they are only reimbursed at 85 percent of the Medicare fee schedule. However, if all the “incident to” criteria are met, the physician extender may bill under the physician’s NPI and be reimbursed at 100 percent of the Medicare fee schedule. When billing Medicare for “incident to” for a physician extender’s services, a practice must adhere to the specific guidelines to be compliant to receive full reimbursement from Medicare.

‘Incident to’ Decision Tree Provides Guide for Billing

The “incident to” guidelines are the following:

  • The NPP has to be an expense to the physician office.
  • “Incident to” must be furnished in the physician office/clinic (or in a patient’s home) setting.
  • There must be direct physician supervision at every service. The physician has to be present in the office suite, but not in the exam room. The physician cannot be out to lunch, seeing patients in the hospital or on his way into the office. If it is a group practice, the “incident to” visit has to be billed under the physician’s NPI who is present in the office the day of the visit.
  • The presenting problem has to be an established plan of care initiated by the physician. “Incident to” cannot be billed for a new patient visit or new problem with an established patient visit.
  • Services have to be within the NPP’s state law scope of practice.

The Decision Tree example included may be used to assist in following the “incident to” guidelines. The Non-Physician Practitioner News published an “incident to” Decision Tree several years ago. This example featured with this overview has been adapted from the Non-Physician Practitioner News, please click here.

The Decision Tree is essentially a series of if-then/yes-no questions. In considering the “incident to” scenarios, the billing decision comes down to determining if the answer is “yes” in meeting the criteria, then the practice can then proceed to look at the next question – moving across the tree until the patient visit satisfies all the guidelines for billing for 100 percent Medicare reimbursement. If the answer is “no” at any stop along the Decision Tree, the Medicare billing must be submitted using the physician extender’s NPI for an 85-percent reimbursement.

Shared/Split Billing

“Incident to” may not be billed in an inpatient, outpatient or emergency department setting. When a visit is performed in one of these settings, the Medicare billing policy of shared/split billing may be used. This is another opportunity for physician extenders to be reimbursed at 100 percent for hospital visits. A shared/split visit is when the physician extender visits and documents the face-to-face time with the patient. Later the same day, the physician would provide and document a face-to-face visit with the same patient.

Under this scenario, both the physician and the physician extender provided and documented same-day, face-to-face visits to the patient at the hospital. Only one evaluation and management (E&M) visit may be billed for this same-day service. The visit may be billed to Medicare under the physician’s NPI for reimbursement of 100 percent. It is imperative that the shared/split documentation guidelines are met to bill under the physician’s NPI. The documentation of what each provider performs is crucial to support this billing. It is not sufficient for the physician to countersign the physician extender note. If the physician extender is the only one from the practice performing the same-day visit, the billing has to be submitted to Medicare with the physician extender’s NPI for the 85 percent reimbursement rate.

The shared/split guidelines are the following:

  • The NPP and physician must be from the same group practice.
  • The NPP and physician face-to-face portion of the E&M documentation must support and confirm the service was performed by both providers. (It is not enough for the physician to just sign his or her signature or document “seen and examined and agree with above” and sign off. An example of accepted documentation would be: “I have personally performed a face-to-face diagnostic evaluation on this patient. My findings are as follows: Patient presents with abscess, onset three days ago. Has tried a warm compress; hot shower for relief.  Exam shows right thigh abscess 3cm warm tender and fluctuant. Incision and drainage not indicated, started on MRSA antibiotic coverage.The documentation would be signed by treating physician).

Importance of Proper Documentation

Medicare and Medicaid are highly visible and frequently accessed federal programs. These programs are regulated and the cost of a billing violation involving a physician extender can run between $5,500 and $11,000 per incident. It is crucial that practices understand the rules regarding “incident to” filings. Training on these regulations is important and it should include the physician, the physician extender and appropriate billing personnel.

Many times in a practice there may be miscommunication between the physician/physician extender and the billing staff. The issue may not come to light until the practice has a change in the administrative team and billing staff as part of a purchase by another entity or during a merger with another practice. Timely billing/coding monitoring and auditing processes are recommended under the Office of Inspector General (OIG) compliance program.

When a review of the documentation is performed and billing vulnerabilities are discovered, these issues may then be addressed. In circumstances where a billing issue resulted in an inappropriate Medicare or Medicaid reimbursement, a practice may engage an attorney to represent the practice in following up with the federal agencies. By self-reporting inappropriate reimbursements to Medicare and Medicaid through the assistance of an attorney, the practice can often avoid significant fines.

The act of self-reporting or submitting corrected claims has additional value as the practice has been proactively addressing issues with reimbursements related to Medicare and Medicaid. This action can demonstrate a commitment to compliance.

We Can Help!

Does your medical practice utilize physician extenders? Does your practice work with Medicare or Medicaid? How is your practice billing “incident to” visits with patients? Elliott Davis Decosimo’s Healthcare Practice has experienced professionals who can assist medical practices in reviewing medical billing records and proper coding/billing. We can help you identify potential vulnerablities and work with you on developing strategies for addressing those issues. To learn more about the services offered through Elliott Davis Decosimo’s Healthcare Practice, please click here.