Test Your Knowledge of 'Incident To' & 'Direct Supervision'

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure information accuracy. However, HMP and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received. 

The 2018 Symposium on Advanced Wound Care Spring conference in Charlotte, NC, saw many wound care professionals and manufacturers asking similar reimbursement questions. By the end of the reimbursement post-conference, this author was convinced that physicians and other qualified healthcare professionals (QHPs) were confused about the “incident to” regulations in physician/QHP offices versus the “direct supervision” regulations in hospital wound care provider-based departments (PBDs). Therefore, this month’s Business Briefs column will provide readers the opportunity to test their knowledge about the Medicare regulations pertaining to these two concepts. Before taking the self-test that appears in this article, readers may wish to refresh their knowledge by re-reading three previous Business Briefs articles that published in 2017.^1-3 The May column discussed requirements to compliantly follow the “direct supervision” guidelines for PBDs in which wound care services are performed and included eight scenarios for readers to test their knowledge.¹ The July column provided a self-test on debridement coding, coverage, and payment.² In August, we discussed Medicare regulations about physicians working in PBDs.³ 

The following self-test (see below) requires everyone to read each scenario, determine if the scenario is correct or incorrect, and, most importantly, explain one’s answer appropriately. After completing the self-test, read the remainder of the article to confirm correct answers. The test has a total of 100 points: 4 points for correctly determining if the scenario is correct or incorrect and 6 points for correctly explaining an answer. 

APPROPRIATELY EXPLAINED ANSWERS 

No. 1: Incorrect. The physician can only bill for the work of an NP performed “incident to” the physician only if the physician and the NP saw the patient together in the PBD. In this scenario, the physician’s office should report the NP’s work on the Medicare claim under the NP’s NPI number. The office should not submit a claim for the physician because he/she did not provide care for the patient.

No. 2: Incorrect. The work (97602) ordered by the physician was performed by a PBD-employed wound care nurse and can only be reported on a Medicare claim by the PBD. The physician should report the correct level of evaluation and management (E&M) performed and documented.  

No. 3: Incorrect. The physician office has a choice to make when the physician is in the office and the NP performs the work. The office can either bill for the work under the physician’s NPI number or “incident to” the physician under the NP’s NPI number. 

No. 4: Incorrect. The wound care nurse is working “incident to” the physician. Therefore, the physician must be present in the office for the physician’s office to compliantly report 99211 on the Medicare claim for the wound care nurse’s work. 

No. 5: Incorrect. PBDs should serve as centers for excellence that manage patients living with chronic wounds that are too complicated to be cared for in a physician’s office but do not require hospitalization. PBDs are not intended to be “dressing change” clinics. Physician offices can easily perform dressing changes for patients who cannot be taught to change their dressings and/or do not have caregivers who can change their dressings at home. Therefore, in this scenario the physician cannot bill Medicare because he/she did not perform the work. Before doing the work, the PBD should explain to the patient that simple dressing changes performed in PBDs are not typically covered by Medicare. If the patient wants the PBD to change the foam dressings, the PBD should present the patient with an advance beneficiary notice of noncoverage (ABN). If the patient signs the ABN, the patient will be responsible for paying to have his/her dressings changed by the PBD nursing staff. If the patient wants the PBD to submit the claim to Medicare, the PBD will attach the appropriate ABN modifier to the Medicare claim to indicate the patient accepts payment responsibility. 

No. 6: Incorrect for several reasons. First, the physician must perform the work in a PBD to compliantly report it on a Medicare claim. Second, the PBD can only compliantly report NPWT under direct supervision, which does not occur on Thursdays in that PBD. Therefore, on Thursdays the PBD can only provide the following services without direct supervision: smoking cessation sessions (99406/99407), application of Unna’s boot (29580), and application of multilayer high-compression bandage system (29581).

No. 7: Incorrect for several reasons. First, the physician who performed the procedure is obligated to dress the wound in the office after the debridement is performed. Second, the PBD does not meet the medical-necessity requirements if the wound care nurse only performs dressing changes. 

No. 8: Incorrect. The work was performed in the PBD. The physician should report the correct level of E&M on his/her Medicare claim and the PBD should report 29581 on the facility’s Medicare claim. NOTE: If this work was performed in a physician office, the office would have reported 29581 because the work was performed “incident to” the physician. 

No. 9: Incorrect. The PBD does not have direct supervision. Nobody can bill for this scenario because the HBOT should not occur unless a physician/QHP is immediately available to provide direct supervision before the PBD begins the HBOT. If not, the PBD should reschedule the patients for another time when the PBD will have direct supervision. 

No. 10: Incorrect. The surgeon is not in the office when the NP performs the HBOT supervision. In addition, the surgeon and the NP should verify that the respective state practice act allows NPs to perform HBOT supervision. If the NP is permitted to perform the HBOT supervision in that surgeon’s state, then 99183 should be reported under the NP’s NPI number on the Medicare claim. 

SUMMARY 

Direct supervision in a PBD requires a physician or other QHP to be immediately available to furnish assistance and direction throughout the performance of the procedure. Immediately available is defined by the Centers for Medicare & Medicaid Services as “physically present, interruptible, and able to furnish assistance and direction throughout the performance of the procedure, but without reference to any particular physical boundary.” In PBDs, direct supervision is required for all work performed except for smoking cessation sessions, application of Unna’s boot, and application of multilayer compression bandages. PBDs should not bill the Medicare program for dressing changes; patients should pay the PBD for that service, change their dressings at home, or have the dressings changed in a physician’s office. In addition, physicians/QHPs can only report on Medicare claims the work they perform in PBDs. In physician/QHP offices, services such as dressing changes by a wound care nurse can be reported on Medicare claims if all the “incident to” regulations are followed:

• Documentation must show a link between the “incident to” service and the plan of care established by the physician at the initial visit.
• Documentation must show that the supervising physician was involved in the care of the patient and was present and available during the visit providing “direct supervision.”
• Documentation must include: 1) evaluation that shows relevant and necessary clinical exchange of information between the provider and patient; and 2) management that shows the influence of the service on patient care, such as medical decision-making, patient education, etc. 
• Documentation must include the signature and credentials of the auxiliary personnel who performed the service.
• Documentation must include the date of service. If the physician is not in the office, the office cannot submit a bill to Medicare for the wound care nurse’s work. Direct supervision and “incident to” in the physician office setting does not mean that the physician must be present in the patient’s examination room with the wound care nurse. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the wound care nurse is performing services for the patient. The situation is different for NPs: If the physician is present in the office, the office has the choice of reporting either the physician’s NPI number or the NP’s NPI number on the Medicare claim, if the NP cares for the patient. 
• If the physician office prefers to submit “incident to” Medicare claims under the physician’s NPI number for the work of NPs in the office, the physician must be present in the office suite, but does not have to provide a service to the patient at each visit. However, to bill the NP’s work “incident to” the physician, the physician must have furnished a direct personal professional service to initiate the course of treatment, the service performed by the NP must be an incidental part of the initial service, and the physician must provide subsequent services that reflect the physician’s continuing active participation in and management of the course of treatment. Additionally, the physician must be physically present in the same office suite and be immediately available to render service, if that becomes necessary.  
• If the physician is not present in the office suite, the office should report the NP’s NPI number on the Medicare claim, rather than the physician’s NPI number. 

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@bellsouth.net

References

1. Schaum KD. Business briefs: direct supervision in the provider-based department: what’s required? TWC. 2017;11(5):6-8.

2. Schaum KD. Business briefs: test your knowledge of debridement coding, coverage, & payment. TWC. 2017;11(7):6-8.

3. Schaum KD. Business briefs: working in a wound care provider-based department: the medical director’s perspective TWC. 2017;11(8):5-8.