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Changes to Incident-To Billing; Time-Based Coding


Answers from our coding expert on questions regarding incident-to billing; time-based coding; and specificity in ICD-10.


Q:  Many times in the past few years the [Office of the Inspector General] Work Plan for Physicians has indicated that they are monitoring 'incident-to' billing in physician's offices but nothing ever seems to change. Are they planning to get rid of the provision that the nonphysician provider (NPP) can’t see new problems under incident-to, like UTI’s and the like?

A:  You picked a good time to follow up on incident-to, because there is a change in guidance coming up, although not the one you want.

The rule about the NPP not seeing new problems is still in place for Medicare.  If the presenting problem is a new problem not previously evaluated by the physician, the NPP cannot bill incident-to, but should instead bill under his own national provider identifier (NPI). If a documentation review uncovered an NPP billing for an acute new problem, the service would be denied as "Payment adjusted as not furnished directly to the patient and/or not documented."

What is about to change comes out of the physician fee schedule guidance: "'Incident-to Policy for Calendar Year 2016."

In some cases, the physician or practitioner supervising the service is not the same individual treating the patient more broadly. For 2016, CMS is finalizing a proposal to specify that, in those cases, only the supervising physician or practitioner may bill Medicare for incident-to services. Additionally, CMS is finalizing a proposal to require that auxiliary personnel providing incident-to services and supplies cannot have been excluded from Medicare, Medicaid, or other Federal healthcare programs by OIG, or have had their enrollment revoked for any reason at the time that they provide such services or supplies.

The change to supervising provider versus the patient's own personal provider of record may cause more services to be billed in the name/number of the NPP. Until now, when the patient's physician of record was not in the office or clinic, the physician that was present could become the supervising or billing provider for the day. Those days seem to be numbered.


Q: I have noticed that some of my OB/GYN providers are mismatching the fourth or fifth digits indicating the trimester, when using multiple ICD-10 codes in the same encounter. Is ICD-10 somehow causing this?

A: The whole concept of trimesters in coding has come along with the ICD-10 coding system. However, there is nothing inherent in the coding system that would cause mismatches or incorrect assignment of these indicators.

As you know, in the fourth or fifth character, 1, 2, or 3 is used to indicate the first, second, or third trimester, both on the normal supervision of pregnancy codes and on codes representing problems in pregnancy.

I suspect that any error here is likely human in origin. A code like Z34.83 - Encounter for supervision of normal pregnancy, third trimester shouldn't have many other codes along with it to cause problems. But a code like O09.93 - supervision of high-risk pregnancy, unspecified, third trimester, might be coded along with something like O16.3 - unspecified maternal hypertension, third trimester.

In a situation like this, we've seen the O16 code with an O16.2 coded in the third trimester. And there is a simple explanation. The provider assigns the correct code for the O93 series code based on today's estimated gestational age but when they go to assign the second code, they click on the maternal hypertension code assigned in the last encounter or some prior encounter, which may have been in the prior trimester. They just didn’t update the fourth digit to reflect the current trimester. So in this case, ICD-10 didn't do it exactly. But welcome to the world of specificity and impermanence.


Q:  I have a part-time practice in which I do a lot of lifestyle counseling. Therefore, I end up doing a lot of time-based coding as counseling. I was reviewing one of your previous articles on time-based coding and had a question. Can we only code based on time for the first time we are counseling someone regarding a given issue? Or can we code based on time every time we counsel them, even if it's regarding the same issue over and over? For example, many patients with IBS require ongoing counseling regarding diet and lifestyle. Is it appropriate to code based on time/counseling for a single issue on recurrent visits?

A: The concept of coding by time was offered by the AMA as an alternative to the more common evaluation and management (E&M) history, exam, and decision-making components, because some visits just aren’t the standard SOAP format. There are many visits where patients present "to review test results" or something similar. In your case, counseling seems to be the appropriate action.

There are no frequency limitations on coding by time. If the nature of the encounter is counseling - document it and code by time, as often as is medically necessary.

Remember that a payer doesn't know how you support any given code unless they look. It would be on chart review that a question could arise as to the frequency of coding by time, the accuracy of the times, and the necessity of the service.

You could trigger a review by significant reporting of high-level codes, perhaps representing longer sessions. Once the nature of the services was clear, you may have to answer some necessity questions.


Q:Can I bill the 99406 and 99407 smoking cessation codes to inpatients? Along with hospital admits? Consults? Critical Care? Follow-up visits? I like to reinforce prevention and lifestyle choices when the patient is most receptive.

A:  Yes. There is no coding or bundling issue preventing you from billing either of those codes with the services that you specified. There are, however, a couple of things to consider.

There are limitations on the number of times a year that payers, certainly Medicare, will pay for these codes. So save some for primary care (unless you are very persuasive).

Second, although there is no actual edit to prevent this, these codes would appear unusual along with critical care. The general sense being that if the case is so acute or life-threatening, counseling on smoking cessation might seem untimely. But to your point, perhaps it is the best time.

Facing a coding conundrum? We're here to help. Send your questions to coding expert Bill Dacey at billdacey@msn.com. He will help clear up the confusion, and you may even see your question featured in the journal.

This article was originally published in the March 2016 issue of Physicians Practice.

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