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Q:

I am a nurse practitioner who has joined a pain management practice. We plan to practice "incident-to" billing when the physician is here on site. However, there will be times when he is not in the office. If I apply for a Medicare number, can I use my own number when he is gone and bill at 85%? We were told by our billing company that if I get a Medicare number, we won't be able to bill "incident-to" when the physician is here. Any insight you can give into this question would be appreciated.

A:

We recommend that licensed mid-level providers bill incident-to when the Medicare guidelines are met since reimbursement under these conditions is 100% of the allowable. For Medicare purposes the following criteria must be met:
  1. You have an employment relationship (this includes leased and contracted staff) with the physician;
  2. You are not billing incident-to for new patients;
  3. You are not billing incident-to for established patients presenting with a new problem; and
  4. The services you are providing are provided in the office and are integral to the physician's services.
Your billing company is partially correct, but it should not prohibit you from billing incident-to for services provided to established patients as long as the physician is present in the office suite and you are practicing within the scope of your license.

When the physician is not in the office or when you have a new patient or an established patient with a new problem, you should bill under your own Medicare number. Reimbursement will be 85% of the allowable. The billing company should bill the practice's regular charge without discounting it. Medicare will make the adjustment automatically.

Your billing company should review the Medicare's recent transmittal regarding split billing. It can be found here http://www.cms.hhs.gov/manuals/pm_trans/R1776B3.pdf. Thank you for your question.

 

Mary Beth Black, CPC (bio...)
Senior Associate

MMA does not provide legal, accounting, or tax advice.  If you need assistance in these areas, we recommend that you consult a qualified professional.  In addition, please note that a client relationship with MMA is not established by the submission of a question to this forum or by the publishing of MMA's response.



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