Physician Billing for “Incident to” and Shared Care Services

1
Solving the Mysteries Around Incident
to Shared Care
2
Objectives

• Define QHP providers
• Identify clinical staff and services they can
  provide
• Understand which services require orders
• Explore the difference between incident to and
  shared care services.
• Review specific guideline for each service
• Understand reimbursement issues
• Look at how other payers view these Medicare
  policies

3
Basics

• All physician groups that employ QHPs may be
  faced with billing Medicare for their services.
• The key issue is differences in reimbursement
  based on who reports a service
• Medicare reduces QHP billed services by 15 of
  the physician allowed amounts
• Huge compliance issue

4
QHP/NPP

• A QHP/NPP is a licensed health professional
• Recognized by Medicare as able to evaluate, treat
  and be paid for medically necessary services on
  the Part B physician fee schedule
• Qualified by education and training
• QHP must meet eligibility requirements to be
  credentialed by Medicare and bill independently
• Examples nurse practitioner, physician
  assistant, clinical nurse specialist, certified
  nurse-midwife

5
Clinical Staff

• Person who works under the supervision of a
  physician or other QHP professional
• Allowed by law, regulation and facility policy to
  perform or assist in the performance of a
  specific professional services
• 99211 or specific code based on TOS
• Service billed under physician QHP name
• Includes medical assistants, licensed practical
  nurse, etc.

6
Incident to Requirements

• Performed in physician office
• Physician provides direct supervision
• Physician must be present in the office
  suite and immediately available to furnish
  assistance and direction throughout the
  performance of the procedure.
• Supervising physician can be any physician in the
  clinic
• Does not have to be physician the initiated care

7
Documentation

• Identity of performing provider
•  Note indicating name of supervising/billing
  physician was in the office suite at the time of
  the service.
• Preferable to have physician order available that
  ordered follow up by QHP or ancillary service

8
Split/Shared Care

• Shared or split services are Evaluation and
  Management (E/M) services performed jointly
  between a physician and a non-physician
  practitioner (NPP), in the same group, in a
  facility setting.
• May not be performed in office setting (POS 11)
• Services may include both face-to-face and
  non-face-to-face activities.

9
Commercial Payers

• Some may specifically exclude incident to
• Cigna
• Some payers do not credential QHPs and services
  should be billed under the supervising physician

10
Commercial Payers

• UHC allows incident to and shared care billing.
  
• May require modifier SA for incident to services
• HighMark follows incident to guidelines and
  require
• If a particular payer credentials QHPs they may
  follow incident to or shared care rules
• Check with your individual payers

11
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