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NIAtx SASS Conference EHR Best Practices Presentation

Handout 2 Implementation Plan Outline

Handout 3 Work flow outline

The number of elderly and disabled that seek Behavioral Health services is increasing. Unfortunately, there seems to a perpetual lack of clinicians eligible to bill Medicare (Note: The following are eligible for their own Medicare billing ID number: MD, CNS, PhD Psych, Social Worker, NP – restrictions apply, see the Medicare Website for more details). As the demands increase, more and more agencies are turning to Incident to billing. Incident to billing allows a non-Medicare eligible clinician to bill, incident to, an eligible Medicare professional (with her own billing number). The rules for billing Incident to services are very strict. Not following the rules can invite unwanted audits and financial take backs.  Behavioral Healthcare agencies can bill incident to an MD, clinical nurse specialist (CNS), or nurse practitioner (NP). 

Incident to: Think of billing “incident to” another person as “in place of” Medicare pays for the service as if it were performed and billed by the MD, CNS or NP (see 42 CFR § 410.76). Below, you can substitute CNS or NP for MD. For the purposes of this article – we will consider a patient being seen by an psychiatrist and a Social Worker with no Medicare billing ID number. The Social Workers’ services will be billed incident to the psychiatrist.

What are the requirements? The following are the requirements for billing Incident to.

1. The Client must be initially seen by the MD and she/he must stay involved in the care. At a minimum, an evaluation by an MD must be performed before the incident to services (usually individual therapy). The MD must make the initial diagnosis, develop the treatment plan, and remain involved. There is no requirement for the MD to see the client before each session. Massachusetts Medicare regulations say that the MD must see the client as is medically necessary. I recommend that the client be seen by the MD yearly at a minimum. According to the Medicare Administrator for Massachusetts, NHIC, “The patient’s medical condition is the determining factor as to the frequency the supervising physician reflects his active participation and management of the course of treatment. ” (11/11/10 NHIC Memo). It is a good idea to check with your MAC for any other incident to requirements. A full listing of Medicare Administrative Contractors and their jurisdictions is available on the web.

2. The care provided by the social worker must integral, although incidental. “Incident-to a physician’s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.” (Source: Mental Health Services Billing Guide, July, 2010, CMS)

3. Documentation – The MD must write an order for treatment, that includes the Incident to work in the chart. For example, “Client will benefit from weekly individual therapy to address depression.” This should be included in the MD’s evaluation or treatment plan.

4. Medical Necessity – As with all clinical work, medical necessity must be established and maintained.

5. Location: The services must be performed in an office, and a supervising MD must be in the same office suite. The supervising MD is the one you will bill Incident to. The supervising MD does not need to be the same one that sees the client for the initial evaluation or treatment. You should be able to prove that the supervising MD was on site during the time period that the incident to services were being performed. The best way to do this is a two pronged approach – 1. keep a log of the MD on site and 2. be able to show that the MD was billing for their own services at the same time as the incident to services were being done. The MD should also sign in and out of the log. The MD must also be readily available should her or his assistance be needed. The MD present must also be there to do direct clinical and not administrative work. Obviously you will want to coordinate your sessions for when there is a supervising MD on site seeing clients.

6. Your staff need to perform the service. The “incident to” services must be provided by personnel that represent a direct financial expense to the physician, or agency, such as a W2 employee, leased employee, or independent contractor.

7. Providers that can work incident to: Medicare states that “Auxiliary personnel” can provide services incident to an eligible provider. These providers must have the skills and training to perform the services being billed; there is no definitive list. It is best to check with your MAC to confirm eligibility. (note: I have asked NHIC for a definitive list and will update this posting if new information becomes available).

8. Reasonable Expectation of Improvement (taken from Medicare): “Services must be for the purpose of diagnostic study or be reasonably expected to improve the patient’s condition. The treatment must, at a minimum, be designed to reduce or control the patient’s psychiatric symptoms so as to prevent relapse or hospitalization and improve or maintain level of functioning. The goal of a course of therapy is not necessarily restoration of the patient to the level of functioning exhibited prior to the onset of illness, although this may be appropriate for some patients. For many other psychiatric patients, particularly those with long-term, chronic conditions, control of symptoms and maintenance of a functional level to avoid further deterioration or hospitalization is an acceptable expectation of improvement. “Improvement” in this context is measured by comparing the effect of continuing treatment versus discontinuing it. Where there is a reasonable expectation that a patient’s condition would deteriorate, relapse further, or require hospitalization if treatment services are withdrawn, this criterion would be met. ”

Other issues:

1. In addition to your other internal audits – it is a good idea to do a yearly Incident To Medicare audit. The eight areas above should be reviewed in addition to your normal chart audit review.

2. If you have to pay back money, be sure to closely follow the Medicare and OIG rules for paying money back. Keep detailed notes about your paybacks as this established a pattern of self auditing and voluntary refunds.

3. If paying back – be sure to evaluate whether you need to also refund secondary payer claims.

4. It is very helpful to have a written Policy and Procedure on Medicare Incident to billing in place before there is an issue.

5. Sign up as many eligible providers as possible to reduce the amount of incident to billing. For information on enrolling – see the Medicare Website (an NPI number is required).

For more information see:

Medicare Mental Health Services Billing Guide

Solutions EHR Implementation White Paper

06.30.10  Responding to a Breach 06.30.10

07.26.10   Why You Need a Social Media Policy 07.26.10

08.03.10   Meaningful Use – What’s in it for Behavioral Health 08.03.10

10.31.10    Do You Need a Consumer Portal 10.31.10

11.01.10   Compliance Essentials for Behavioral Health Care 11.01.10