How to Avoid Common Medical Billing Compliance Pitfalls?

There are several major issues facing compliance officers today, such as HIPAA, Stark Law, and Anti-kickback Statute issues, as well as many billing compliance issues. Billing issues continue to appear in federal government False Claims Act settlement agreements and government audit reports. Here, we’ll discuss incident-to and shared billing compliance pitfalls and focus on what you can do to fix problem areas.

Incident-to Billing:

The “incident-to” billing rules provide an exception, allowing 100 percent reimbursement for non-physician services that meet the requirements detailed in the Medicare Benefit Policy Manual, Chapter 15, Section 60 (Services and Supplies Furnished Incident To a Physician’s/NPP’s Professional Service).

There are six basic requirements to meet the incident-to guidelines for Medicare payment:

  1. The service must take place in a non-institutional setting
  2. A Medicare-credentialed physician must initiate a patient’s care
  3. Subsequent to the initial encounter (during which the physician arrives at a diagnosis and plan of care), an NPP may provide follow-up care
  4. A physician must actively participate in and manage the patient’s course of treatment
  5. Both the credentialed physician and the qualified NPP providing the incident to service must be employed by the group entity billing for the service (if the physician is a sole practitioner, the physician must employ the NPP)
  6. The incident-to service must be the type of service usually performed in the office setting and must be part of the normal course of treatment of a diagnosis or illness

Shared/Split Service:

A split/shared evaluation and management (E/M) visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified non-physician practitioner (NPP) each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service.

The split/shared E/M visit applies only to selected E/M visits and settings (i.e., hospital inpatient, hospital outpatient, hospital observation, emergency department, hospital discharge, office and non-facility clinic visits, and prolonged visits associated with these E/M visit codes). The split/shared E/M policy does not apply to critical care services or procedures. We mentioned common split/shared visit scenarios for better understanding.

Hospital inpatient/outpatient/emergency room setting:

When a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician’s or the NPP’s National Provider Identifier(NPI). Example: If the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service.

Office/Clinic setting:

In the office/clinic setting when the physician performs the E/M service the service must be reported using the physician’s NPI. Example: In an office setting the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the “incident to” requirements are met, the physician reports the service. If the “incident to” requirements are not met, the service must be reported using the NPP’s NPI.

Documentation for split/shared visits should follow the documentation guidelines for any E/M service:

Each physician/NPP should personally document in the medical record his/her portion of the E/M split/shared visit and legibly sign and date the record. The documentation must support the combined service level reported on the claim.