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Tip: "Incident to" services: Don't fall prey to the OIG

Compliance Monitor, April 7, 2004

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OIG auditors have been busily investigating outpatient cardiac-rehabilitation services, and as a result, they are scrupulously searching for services inappropriately billed as "incident to." If the OIG comes knocking, the HIM department should be prepared. Use the following guidelines to better understand incident-to requirements and thereby ensure correct billing for these services:

1. The "services or supplies are furnished as an integral, although incidental, part of the physician's services in the course of diagnosis or treatment of an injury or illness." This means the physician has included the services as part of the plan of care, and has established a diagnosis and course of care. Physicians cannot bill Medicare for new patients or for established patients with new problems. There must be frequent and subsequent services to reflect continuing, active management of the treatment.

2. The physician's office or clinic must commonly furnish the type of services being billed as incident to. Physicians shouldn't bill for incident to services performed in an inpatient or outpatient hospital setting, and services performed during home visits or in nursing homes should only be billed if the physician is physically present.

3. The physician must always provide direct personal supervision for the services to meet requirements. If a nonphysician practitioner (NPP performs services in an office setting, the supervising physician must be present in the office suite and immediately available to direct the NPP if necessary.

4. The NPP must be an employee of the physician or group practice. He or she may be a full-time, part-time, contracted or leased employee of the supervising physician, or physician group practice. The NPP may also be a staff member of the legal entity that employs the physician who provides direct personal supervision. Getting a grip on the OIG's targets will help you promote concise documentation and guarantee OIG compliance.

This week's tip is adapted from the book, Compliance Troubleshooter: Tackling the top 10 compliance challenges. Copyright 2003 by HCPro. For more information, click here.

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