8/7/18 NAMAS Webinar Q&A "Incident-To for Medicare"

Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.

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Wed Aug 08, 2018 9:12 am

Hello all,

For those of you who asked questions live and were unable to receive answers, Michael has responded to each and the list is compiled below. If you have any follow up questions, please feel free to contact the speaker directly or send them to us at namas@namas.co. Thank you!

Disclaimer: These questions were copied and pasted without spell check or any attempt at editing for clarity directly from the webinar Q&A feed. The answers were compiled after the fact by the webinar speaker.

1) does these procals need to be documented within the MDM of the pt's visit?
A: Documentation of the identity of the performing and supervising provider can be anywhere in the note.

2) to go back to the signature. as long as it's identified with a line prior to signature, stating I agree with plan and/or supervised
A: The physician agreeing with the plan doesn’t help. You need evidence that the physician was the decision-maker in implementing the plan. “After consultation with Dr. X, Dr. X ordered the following change to the treatment: [STATE CHANGE].

3)For established patients seeing a specialist in routine f/u every 6 months to 1 year, is incident to up through 12 months sufficient to demonstrate continued physician involvement and anything over 12 months would require the physician to see the patient again (assuming no new problems)?
A: Depends on the state licensure rules or the supervising/collaborative agreement in place with the mid-level as to what active involvement requires.

4) Being Medicare credentials retro to the new physician's start of employment date would this scenario occur?
A: Medicare credentials are retroactive to the effective date, which is the date the application was accepted by CMS as complete. That date might be the employment date but usually is not.

5) If during the visit the NP identifies and brings in the physician or discusses with the physician the new issue can the visit still be billed incident to if the physician makes the decision for treatment of the new issue and it is documented in the dictation?
A: Yes, as discussed, this is a split shared visit. The physician’s analysis of the new problem is, of course, billed under the physician since it was his or her own work.

6) The mid-level’s work for the existing problem, provided that all I2 requirements are met, is also billed under the physician as permitted under the I-2 rule.
Is it sufficient for the supervising physician to state in the NP's note "I saw and examined the patient and agree with the plan of care?"
A: No, that the physician agrees with the NPs plan of care does not mean that the physician is in control of the care or initiated the care. In this scenario the physician is not the decision-maker. Instead, such a statement just means the physician hired a competent NP.

7) Transitional Care management face to face says it has to be direct supervision. If an NP goes to the home and is billed under their own number, can they perform transitional care management in the home?
A: The home care exception to the direct on-premise supervision requirement does not apply to transitional care management. Only certain therapeutic services and only in certain underserved areas. If TCM is performed by NP in the home, bill under the NP. Such services cannot be billed I2.

Follow up question: I didn't understand his response on transitional care. So, he is saying it is allowed under their own number?
A: Of course, a provider performing a service in their own right can always bill services they personally perform under their own number.

8) Hi. To revisit billing physician services incident to another physician for that new physician credentialing scenario, have any MACs given their stamp of approval on that? The idea of that being acceptable kinda blows my mind. Thanks!
A: I don’t know of any formal guidance. It is just what the regulation permits under the explicit definition of auxiliary person.

9) What about Hospital Outpatient. I am receiving argument that I am taking things "Too literally" when I say it can't be billed there.
A: If a hospital based out-patient clinic, the rules are the same with the understanding that direct on-premise supervision is limited to the office suite.

10) What about incident to billing in hospital-based clinics
A: See answer to #9 above.

11) Are incident to rules the same for FQHC clinics and if not can you highlight the differences?
A: I am not aware of any exceptions for FQHC.

12) "Provider uses Paper Charts. Has a stamp which goes like this:
“Case reviewed with Jane Doe, NP I personally interviewed and examined patient” and then Provider name is stamp print John Doe MD and has his initials scribbled in pen." Is this compliant for Incident-To Provider co-signing and thereby demonstrating his/her participating in the patient’s plan of care? Is the use of stamp as a template ok for documentation? Kindly advise. Thanks!
A: This does not demonstrate compliance with the I2 rule, especially if the initial visit. Who initially evaluated the patient, formed the DX and plan of care? If the NP and the doc added this stamp, all this means is that the doctor agrees with the NP’s decision-making. As such, the NPs work is not integral/incidental to the physician’s professional work. In fact, the opposite appears true. At best, this statement might substantiate the active involvement requirement if a subsequent visit and if that is all the relevant licensure rule requires.

13) If the midlevel is seeing the patient & makes a medication modification whether is just milligram or frequency of use, does this cause incident-to to not be allowed because of the modification to the plan?
A: We discussed this scenario during the lecture. There is no bright line as to how much of a change might be acceptable to CMS before they become concerned that the NP is directing the care instead of the physician. For that reason, I would substantiate that any change was either a) ordered by the physician expressly or that b) the change was consistent with in-office written patient management protocols (if this finding is evident, do that…).

14) when you say "protocol' to be able to modify rx & still be incident2.. as in that particular plan of care for that patient or an office policy? Can you clarify?
A: A patient management protocol is as described in the answer to #13 above. It is a specific advanced order for management of a particular disease or condition where a specific change in say a lab result or test result prompts a specific change to the medication. This commonly occurs with patients on say coumadin – their prothrombin value is X, which prompts a dosage change to Y. The key is that it eliminates the mid-level from engaging in medical decision-making – the physician has already decided what should occur.

15) Injections performed by APs can be billed incident-to? Not just the E/M?
A: Any service that can be routinely performed in an out patient office setting.

16) What are the documentation requirement for incident-to?
A: Documentation sufficient to demonstrate compliance with the rule. See the slide near the end of the presentation.

17) If Dr. Smith left the practice and his patient came [for a followup visit’ and was seen by the NP. Can this encounter be billed incident to Physician that is present in the clinic that day?
A: In theory yes. The fact that the original ordering physician has left the practice is irrelevant since a service that is billed incident-to is billed under the supervising physician. Whether the visit in question is reportable as an I2 service under the supervising physician or not depends on whether the other elements of the rule are satisfied.

Summary: Get in the habit of evaluating compliance with each element of the Incident-to rule in every case where the service was performed by an auxiliary person. Don’t assume anything!

Your questions have been answered by the webinar presenter, Michael Miscoe, Esq.
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Wed Aug 08, 2018 12:42 pm

Thank you for answering all the submitted questions and for posting this Q & A.
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