Even though many practices employ nurse practitioners, physician assistants, and other nonphysician practitioners (NPP) to make the office more efficient, some simply do not use them optimally or have the right personnel performing the right tasks. Moreover, practices may not be aware of coding regulations when services are rendered by NPPs, which may result in improper coding and inadequate reimbursement.
Perhaps most important from a business standpoint is to make sure that the NPPs are following regulations to ensure proper coding of the services they provide, and, in turn, ensure that the practice receives proper reimbursement.
"The biggest problem is that they are underutilized, then when they are utilized, they are not utilized properly," says Maggie M. Mac, CMM, CPC, CPC-E/M, ICCE, consulting manager at accounting firm Pershing Yoakley & Associates. "I think the biggest problematic area is misunderstanding or misuse of incident-to, and they get into trouble for this because there is a lot of focus on this from the [Office of Inspector General (OIG)]."
Incident-to services are those that are performed by an NPP and can be billed to Medicare. To qualify as incident-to services, Medicare requires certain regulations to be followed, including that an NPP can see a patient that has previously been seen by a physician, as long as the physician has written down a plan of treatment.
When the NPP sees the patient for follow-up, he or she must follow the physician's treatment plan to the letter, Mac says. If the physician makes any changes, or there are new problems or symptoms to be reviewed, the practice has to bill it differently and may not be able to maximize profitability, she says.
"Under the physician's name, [Medicare] pays it at 100%," Mac says. "Even though [the NPPs have] performed the work, they've actually carried out a plan of treatment without any changes or seeing the patient for any new problems. They can bill it under the physician's name, get 80% of 100% reimbursement versus if they billed it under their own ID and number, they would get 80% of 85% of the allowance."
Under incident-to rules, a physician has to be in the building when the service is rendered, but it does not have to be the same physician that outlined the treatment plan either, simply a physician from the practice, Mac notes.
However, NPPs and physicians need to be aware of the coding and billing rules. Without that communication, there could be OIG sanctions due to coding violations.
This article was adapted from one that originally ran in the January 2009 issue of The Doctor's Office, a HealthLeaders Media Publication.