Medicare Criteria Discussion Paper

Incident-to Billing per the Medicare Criteria Discussion Paper

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Incident-to Billing per the Medicare Criteria Discussion Paper

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For this week’s discussion board, I chose the topic of “incident-to” billing, as known as shared billing. Though I pulled information from multiple articles to define and discuss the topic of incident-to billing, the main article, for the purpose of this assignment is from Carolyn Buppert entitled “‘Incident-to’ Billing Explained.

Who Uses It, When, and Why?”. Incident-to billing is defined as services that can be billed at the physician’s higher rate of reimbursement, though the services were provided by someone other than the physician, such as the nurse practitioner (NP), physician’s assistant (PA), and even the staff nurse, depending on if a certain criterion has been met (Buppert, 2016a).

Summary of Article

The article by Buppert (2016a) touches on the topic of Incident-to billing per the Medicare criteria. The article explains that when the outlined criteria are met, billing can be placed under the national provider number (NPI) of one provider, though services were provided by another person.

Most circumstances of incident-to billing may be looked upon as if the physician is taking the credit for the work and skills that were provided by the NP/PA, allowing for them to get less of the accolades for the work and maybe even discounting the NP/PA’s judgment and the care that they are providing because the reimbursement is at a discounted rate.

This interpretation of the NP/PA’s judgment and care is unfounded. Hooker and Muchow (2015) report that the care of the NP/PA has been proven to be better than that of the physician in some circumstances, with the added bonus of it being less expensive (Kenny, 2016).

Collaborative versus Independent

The NP/PA in my state, North Carolina, must work in collaboration with a physician. The higher reimbursement can be billed if the visit is in an office setting, documentation of participation from the physician is provided with a note that the physician reviewed the plan of care, and if the NP/PA provides care to a patient that the physician had previously established a plan of care (Painter & Painter, 2018).

Another way collaborative care can be billed on a higher reimbursement level is by using current procedural terminology (CPT) codes (Hughes, 2017). An example of CPT usage is that of an example provided in the article by Buppert (2016a), this is when the NP has seen the patient for a blood pressure issue and asks the patient to return for a blood pressure check at a later date.

The patient will return to have the blood pressure checked by the clinic nurse, allowing for the NPI number of the NP to be used for higher reimbursement. In states that do not require collaboration with a physician, billing will obviously be regulated differently.

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Legal and Ethical Implications

From all the references that I have read and some of those are listed below, it appears that fraudulent billing is typically the most common issue. Physicians or the financial billing department of a facility could possibly code visits at the higher reimbursement, though the physician may not have had a true hand in the care of the patient.

The biggest thing I have taken away from this assignment is the importance of protecting your name and credentials (Buppert, 2016b). The NP must take great care in protecting their NPI as it can be used falsely in billing. The repercussions of this falsification can result in legal ramifications against the NP.

References

Buppert, C. (2016a). Incident-to billing explained: Who uses it, when, and why? Medscape. Retrieved April 12, 2020, from https://www.medscape.com/viewarticle/869335#vp_1

Buppert, C. (2016b). Legal limits: 3 ways to protect your career. Journal for Nurse Practitioners, 12(8), 575–576. https://doi-org.ezp.waldenulibrary.org/10.1016/j.nurpra.2016.06.010

Hooker, R.S. & Muchow, A.N. (2015). Modifying state laws for nurse practitioners and physician assistants can reduce cost of medical services. Nursing Economic$, 33(2), 88–94.

Hughes, C. (2017). Coding & Documentation. Family Practice Management, 24(2), 36.

Kenny, C. (2016). Physician Incident-to Billing and Shared Services. Dennis Barry’s Reimbursement Advisor, 31(7), 3–6.

Painter, R, & Painter, M. (2018). NP, PA incident-to billing: What is (and isn’t) allowed. Urology Times, 46(7), 31.

Incident-to Billing per the Medicare Criteria Discussion Paper

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