As long as the carrier's incident-to rules are met, there's no problem. When the rules are broken, there's a problem.
Want to keep things humming along in your busy office while you run next door to the hospital to discharge a patient? Having your physician assistant handle a few of those routine follow-up visits while you're out is fine -- but not if you plan to charge Medicare your full fee.
Todd Welter, a Denver-based management and coding consultant, describes how a small-town physician got into hot water when he ran afoul of Medicare's incident-to billing rules, which require a physician to be on premises, though not necessarily in the exam room, in order to bill for services at the physician rate.
"In a way he got caught trying to do the right thing," says Welter. "He was putting his patients first. Being a committed small-town doctor means you have to be in two places at once. But he also blundered into a Medicare billing violation." And penalties under the federal False Claims Act can be stiff -- triple damages and fines of up to $10,000 per false claim submitted.
Welter knows the case well because his firm serves as an independent review organization overseeing nearly every detail of that physician's coding and financial practices -- a step required under a three-year corporate integrity agreement worked out by the physician to avoid prosecution. "He can't even buy copier paper without third-party oversight, all ... at his expense," says Welter.
Although an incident-to claim is paid at 100 percent of the physician fee schedule, nothing appears on the claim or in the coding to tell the payer that the physician did not personally perform the service. The nonphysician provider is considered an extension of the physician. As long as the carrier's incident-to rules are met, there's no problem. When the rules are broken, there's a problem -- especially when it's a publicly funded program like Medicare.
Understand the rules
"The frequency of the violation goes to your intent," says Ross D'Emanuele, an attorney with the health law division of Dorsey and Whitney, LLP, in Minneapolis. "Running across the hall for a few seconds isn't the problem. You get a U.S. Attorney's attention when ... they see a number of claims submitted while you are out of the office or out of town."
D'Emanuele says he sees physicians routinely flubbing another key incident-to billing rule -- it's only for office visits.
"A physician who takes a nurse to the hospital to assist with rounding can only bill what he does personally, not anything that the nurse does," he says. "It doesn't matter if the nurse is your employee -- [incident-to] can't be used for anything done where a facility fee is charged."
The Medicare rules also require physicians to remain involved in the patient's care through periodic visits and prohibit the use of incident-to billing for new patient visits. Although the false claims penalties can be steep, failing to use this billing option when appropriate can cost your practice.
The average reimbursement for an established patient's CPT 99213 office visit, according to the 2004 Medicare physician fee schedule, is $53.02, compared with $45.07 for the nonphysician rate -- a difference of $7.95. So billing incident-to makes good business sense. Just make sure you know what qualifies and what doesn't.
Robert Redling is practice management editor for Physicians Practice. Have a story for Physician Beware? Write to