Supervision and Incident-to Guidelines

July 1, 2015 / By Rebecca Caux-Harry

In past blogs, I’ve written about a variety of E&M services and how to code those visits. In case that seemed straightforward, many years ago mid-level providers were added into the mix. You will see these types of providers abbreviated as MLP (mid-level providers), NPP (Non-physician practitioners), NP (Nurse Practitioners), PA (Physician’s Assistants), and some others. For the purpose of this blog, I’ll use MLP. The introduction of these types of providers created a new education opportunity for all of us. CMS created “Incident-to” guidelines and published them in the Medicare Benefit Policy Manual (S60.1-S60.4). This means that an MLP can provide services to a patient and report those services under the physician’s name when those services are provided incident to an established plan of care for that patient.

Billing under the physician’s name when the service is provided by an MLP is a decision to be made by the clinic and it has financial implications. When reporting services using an MLP’s credentials, those services are paid at 85 percent of the amount paid for physician’s services. So, there is an incentive to use the Incident-to guidelines in order to receive the full payment.

The Incident-to guidelines state that an MLP can provide services to patients with an established plan of care and report those services under the physician’s credentials when that physician has provided direct supervision. The supervising physician must be in the office suite and immediately available to the MLP should the need arise. This also means that the patient can NOT be new, or that the patient’s problem can NOT be new. Billing for the services, if following the Incident-to guidelines, must be submitted under the name of the supervising physician, not the patient’s regular provider if they are different, as is often the case. These are Medicare guidelines. Each commercial payer can write their own guidelines. Some commercial payers don’t credential MLPs and require all services provided by MLPs to be reported under a physician’s credentials, regardless of whether Incident-to guidelines were met. Direction from the payer is key to deciding how to bill these services.

Due to the many complexities of Incident-to billing guidelines, many clinics decide to forego these guidelines and take the 15 percent reduction in payment from Medicare and avoid possible erroneous claims. That’s not a bad decision in my mind.

Now, supervision by a physician as a concept also applies to diagnostic testing. There are three levels of supervision:

General: A service is provided under the physician’s overall direction, but the physician’s presence is not required during the performance of the procedure. Direct: A service is provided in the office setting and the physician must be in the office suite and immediately available to provide support. The physician does not need to be present in the room. Personal: The physician must be in the room during the procedure.

The level of supervision required for a specific test can be found in the Medicare Physician Fee Schedule according to the CPT code for the test.

Because the definition of direct supervision of diagnostic testing is the same as that for Incident-to billing guidelines, many coders think the testing supervision guidelines apply to MLPs. They do not. In Chapter 15 of the Medicare Benefit Policy Manual (S80) CMS states that MLPs are not defined as physicians and therefore may not function as supervisory physicians for diagnostic tests. However, if within their scope of practice, MLPs can personally perform diagnostic tests and bill under their own credentials. So review those services carefully before submitting your claims to make sure you are following all of the supervision guidelines correctly and according to each payer.

Rebecca Caux-Harry, CPC, is the CodeRyte product specialist for cardiology with 3M Health Information Systems.

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