Medicare utilizes information provided by the Comprehensive Error Rate Testing (CERT) contractor to select topics for education in an effort to reduce the provider compliance error rate and achieve positive CERT findings in the future. This article includes information on “incident to” and drug administration, and education on accurately billing these services.
Requirements:
- In order for subsequent services to be billed “incident to” the Provider Identification Number (PIN), the provider must have initially seen the patient for the problem being treated and established a Plan of Care (POC).
- The service should be one commonly provided in a physician’s office.
And,
- There should be direct personal supervision by the provider of the auxiliary personnel (regardless of whether the individual is an employee, leased employee or independent contractor of the provider).
Documentation should clearly show evidence of these requirements. Evidence may include:
- A co-signature or legible identifier and credentials of both the practitioner who provided the service and the supervising provider on documentation entries.
- Some indication of the supervising provider’s involvement with the patient’s care. This indication could be satisfied by:
- Anotation of the supervising provider’s involvement within the text of the associate medical record.
Or,
- Documentation from previous dates of service, establishing the link between the two providers.
Dr. Brown originally saw Mr. Smith and established a POC. Sue, a Physician Assistant (PA) employed by Dr. Brown, saw Mr. Smith for his recent visit. Mr. Smith complained of a new problem and Sue provided an Evaluation and Management (E/M) service. She decided it was appropriate to start a series of injections to treat the problem and established a new POC. At the time Mr. Smith presented to the clinic to receive his first injection, which was ordered by Sue, she was not available. A medical assistant administered the injection. The office staff billed this injection “incident to” Dr. Brown (Dr. Brown’s PIN) on this date of service.
Conclusion
The billing staff potentially billed the service incorrectly. Billing accurately for this scenario is determined by whether or not the PA has her own PIN.
Resolution
PA has her own PIN: Dr. Brown must show that he has an active part in the ongoing care of the patient to bill under his PIN. Since Dr. Brown had not participated in the care of Mr. Smith since the new POC was established, this injection should have only been given “incident to” the PA and reported under the PA’s PIN. Therefore, billing the injection “incident to” the physician was inaccurate.
PA does not have her own PIN: When a service is provided by a Non-Physician Practitioner (NPP) who does not have her own PIN, it is common for the service to be billed “incident to” the physician’s PIN. If, however, the physician has not been involved with the establishment or approval of the POC, the service provided by the NPP should not be billed “incident to” the physician.
In the above scenario, where the medical assistant administered the injection when the PA was not available, it would be accurate to bill this service under Dr. Brown’s PIN only if Sue’s documentation establishing the POC revealed a notation created by Dr. Brown showing involvement and approval.
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