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Relevant, Timely Medical and Radiation Oncology News
Constant advancements medical technology and healthcare regulations mean the oncology industry is dynamic and fast-changing. To keep clients on the leading edge of what's happening, Revenue Cycle Inc. maintains the news section of its website as a clearinghouse for oncology news, CPT® coding and/or business operations. Whether it's a legal change that could affect our industry or a tip about oncology coding, you'll find it here.
For more information about how our team of expert consultants can help your practice stay current on these industry changes, visit our medical and radiation oncology service page.
November 2013 Medical Oncology News (View More News and Articles)
Staying Compliant When Billing Incident-to Services
By Ashley Miller, CPC, CHONC, CPPM
“Incident-to” services are performed incident-to, or “as a result of” a physician’s services and are billed using the physician’s National Provider Identification (NPI) number. For example, an injection given by a nurse is an incident-to service; it is performed by the nurse at the direction and under the supervision of the physician. Depending on state laws, a licensed nurse may be allowed to give injections of narcotics. The nurse performs the injection according to his or her licensure and state law; however, the service is billed under the physician’s NPI. An example of incident-to billing in radiation oncology might be a radiation therapist delivering a treatment. The service is provided by the radiation therapist according to his or her licensure; however, the treatment is supervised and billed under the physician’s NPI.
It is important to remember that incident-to applies to physician billing only and is not recognized in a facility setting. This means services provided by a Non-Physician Practitioner (NPP) or licensed staff member in a hospital outpatient or inpatient facility may not be billed under the physician’s NPI by the physician group.
In order to bill incident-to, services must be a result of the physician’s treatment plan and the physician must be in the office suite providing supervision. It is not necessary for the physician to be in the room, but he or she must be in the office to bill incident-to services. Consider the example of a nurse providing an injection to a patient. If the physician is providing rounds at the hospital, the service the nurse performs would not be billable because the physician is not providing supervision.
Medicare has very strict guidelines regarding incident-to services, which are demonstrated in the following quote from a CMS MLN Matters Article. “To qualify as “incident to”, services must be part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment. You do not have to be physically present in the patient’s treatment room while these services are provided, but you must provide direct supervision, that is, you must be present in the office suite to render assistance, if necessary. The patient record should document the essential requirements for incident to service.”
Incident-to services may be performed by midlevel providers as well, such as Physician Assistants (PAs), Registered Nurse Practitioners (RNPs) and other types of NPPs. Services that are performed by an NPP but do not meet incident-to requirements must be billed under the NPP’s own NPI number, assuming the NPP is allowed to perform this service without supervision. It is often thought that NPPs are not able to provide services on their own. This is not true. They may provide services without the supervision of a physician but services are paid at a reduced rate—85% of physician reimbursement—and must be billed under their own name and NPI number. These services are not considered part of incident-to billing.
For an NPP to provide a service outside incident-to billing requirements, there are three issues to consider:
1. Do their state laws, licensure and scope of practice allow them to provide this service outside of
2. Is this NPP credentialed to provide services for this insurance?
3. Does the NPP have privileges to provide services in this facility or office?
Proper billing of incident-to services versus those services provided by an NPP is an important distinction you must make when considering compliance. Through staff education, proper documentation and effective checks and balance, you can achieve your compliance goals. Revenue Cycle Inc. provides focused education regarding medical record documentation and billing processes, including proper application of incident-to policies. If you would like more information regarding consulting services provided by Revenue Cycle Inc., contact us at 512-583-2000.
November 2013 Radiation Oncology News (View More News and Articles)
Don't Risk Lost Revenue from Unnecessary Write-Offs
By Stephania Rodriguez and Matt Terry, MBA, BSRT (R)(T)
Write-offs are an important part of your revenue cycle. The term “write-off” is correctly used to describe bad debt that won’t be recovered. However, many offices incorrectly use this term to describe their contractual adjustments. It’s important to remember that write-offs and contractual adjustments are two completely different concepts, though, and using “write-off” incorrectly could lead to unnecessary loss of revenue.
Terms at a Glance
Contractual adjustment is the difference between what the provider charges and what the provider is allowed to collect under the terms of the contract with the payor, who represents the beneficiary (patient).
Write-offs refer to monies that are charged by providers for services rendered but that cannot be collected. Examples include payments the patient is unable or refuses to make or if an insurance payor has determined the service was not medically necessary.
Deductibles, co-pays and co-insurance refer to the patient’s responsibility for payment.
Medicare claims are filed and processed every day and their results are communicated to the beneficiary and the physician office through an EOB, or Explanation of Benefits. The EOB states the physician’s charge, the payor’s responsibility, the beneficiary’s responsibility and what should be “adjusted off” of the physician’s initial charge as part of his contractual arrangements with the payor.
All adjustments included on an EOB should be verified carefully to make sure each financial party is paying the correct amount, including the patient. The difference between the provider’s charge and the contractually allowed amount should be “adjusted off” of the accounts receivable (AR) as a contractual adjustment. Those monies that are contractually owed but unable to be collected may be considered for write-offs.
Inexperience, idleness and improper incentives for lower AR balances can sometimes cause business office staff to write off balances that could in fact be collected. Revenue Cycle Inc. recommends that providers adhere to a process that requires that all write-offs are carefully considered and pre-authorized by management and physicians. You can appeal a claim if any discrepancies are found within the EOB, but knowing the correct adjustments needed is the key to a successful paid claim and your healthy revenue cycle.
For adjustment codes being used for any line or claim level adjustments, three sets of codes may be used:
- Group Code—Assigns financial responsibility; e.g., CO would mean contractual obligation or provider responsibility and PR would mean patient responsibility.
- CO (Contractual Obligation) => provider is financially liable;
- CR (Correction and Reversal) => no financial liability;
- OA (Other Adjustment) => no financial liability; and
- PR (Patient Responsibility) => patient is financially liable.
- Claim Adjustment Reason Code—Provides an overall explanation for the financial adjustment and may be supplemented by more specific explanation using Remittance Advice Remark Codes.
- A complete list of Claim Adjustment Reason Codes can be found at the following link: http://www.wpc-edi.com/codes
- Remittance Advice Remark Codes—Provides either supplemental explanation for a monetary adjustment or policy information required in the remittance advice transaction.
- A complete list of Remittance Advice Remark Codes can be found at the following link: http://www.wpc-edi.com/codes
Additional information can be found at the following links:
Making sure that proper adjustments are applied is an important step towards your healthy revenue cycle. Through staff education, proper documentation and effective checks and balances, you can achieve maximum collection of services rendered. Revenue Cycle Inc. can assist with implementing best practices in your business. For more information regarding Revenue Cycle Inc.’s services, please contact our consulting team at 512-583-2000 or firstname.lastname@example.org and request a proposal for a full revenue cycle review.