JR - Health Care Compliance Association

By Norman Radies
Editor’s note: Norman Radies is the Chief provider must meet the physician
Compliance Officer for Pediatrix Medical supervision requirements, while the
Group, Inc. He may be reached at services of auxiliary personnel in the
800/243-3839, Ext. 5133.
outpatient setting must meet the
requirements of the “incident to” rule.
Like many physician practice This rule requires the physician to personally
render a professional service to
organizations, increased
utilization of non-physician which the auxiliary personnel’s service is
practitioners (NPPs) has been necessary an incidental, yet integral part [of the
to meet the needs of patients and diagnosis and treatment of a patient’s
clients. Correspondingly, increased regulatory
scrutiny of services rendered by however, that the physician must see
injury or illness]. This does not mean,
NPPs has elevated the need to ensure the patient on each occasion of service
that all your i’s are dotted and t’s are (e.g., routine follow-up visit) by auxiliary
personnel. Use of the “incident to”
crossed. If you do business in multiple
states and serve a Medicaid population rule also requires that auxiliary personnel
are employed by the physician and
in each, you will likely be faced with a
complex set of issues when staffing your are unable to be paid directly for their
practices, scheduling your patients, and services.
billing for services rendered by NPPs.
Since most commercial payers do not The scheduling of patients, staffing of
enroll NPPs and few non-government the practice, and documentation
contracts explicitly define physician requirements are affected by the type of
supervision requirements, this article NPP rendering services, as well as the
will focus on the government payer location and type of services rendered.
requirements, primarily Medicaid. For example, if you schedule a
Medicaid patient for an initial visit
The first step is to gain a clear understanding
of the regulatory distinction office suite, the incident to provisions
when a physician is not present in the
between mid-level providers (i.e., described above cannot be met. Even a
advance nurse practitioners, physician routine follow-up visit (except 99211)
assistants, certified nurse midwives, performed by auxiliary personnel cannot
be billed to Medicaid when a physi-
etc.) and auxiliary personnel (i.e., nurses,
psychologists, technicians, therapists, cian is not present and immediately
and other aides).
available in the office suite (“incident
to” does not apply to the inpatient setting).
Documentary evidence must sup-
In order to bill their services under the
physician’s name and provider identification
number (PIN), a mid-level dent to requirements have been
port that all relevant supervision/inci-
met.
NORMAN RADIES
Lastly, it is important to recognize that
some Medicaid programs limit reimbursement
of NPPs services to as low as
65% of the physician fee schedule
amount.
Each state Medicaid program is authorized
to establish its own physician
supervision requirements for services
rendered by NPPs. Physician supervision
requirements can range from
“physician is available by telephone” to
“the physician must be present and
immediately available to assist while the
service is being rendered.” Maintain oncall
logs and attendance records to support
that supervision requirements have
been met. Some Medicaid programs
require the billing of all services by the
actual provider. In other words, services
rendered by a mid-level NPP must be
billed under the NPP’s name and PIN,
regardless of the level of physician
supervision.
Many state programs maintain a Website
and on-line access to provider manuals.
State Medicaid links are available
through both government and private
sites such as http://www.geocities.com/
medicaid.geo/index.html, Murphy’s
Unofficial Medicaid Page.
Continued on page 12
11
August 2002