Don’t make these common mistakes we find during auditing courses that are easy to miss if you or your coding/billing staff does not understand Medicare guidelines.
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Explore This IssueFebruary 2013
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1. Not knowing when and when not to bill “incident-to.”
A PA can only bill “incident-to” when a physician is physically inside the office—not in the parking lot, not at the hospital, not stuck in traffic—and is seeing an established patient for an established diagnosis. This claim is reimbursable at 100%.
The PA cannot bill “incident-to” if the established patient presents with a new problem and the physician is not physically in the office. What happens here is the PA can continue with the visit, if allowed by state regulations, and bill under his or her own NPI number to receive 85% reimbursement.
2. Confusing what’s known as a “shared visit” for an allowed reimbursable claim.
Here is the real-life scenario:
A PA, or nurse practitioner, is seeing an established patient for an established diagnosis when the patient presents with a new problem. The PA continues with the examination and determines a diagnosis for the new problem. The PA then confirms the new diagnosis with any physician that is available. Later, the physician who was consulted takes the PA’s notes and combines them with his or her own notes about the diagnosis then submits the claim under the physician’s NPI number to receive 100% reimbursement.
This is fraud.
To bill under the physician’s NPI number, the physician must retake the history of present illness to create his or her own documentation. Combining notes with the PA’s HPI is considered fraud because the physician was not in the room at that time.
3. Cloning notes and not checking them twice.
Using an electronic health record (EHR) system creates a more efficient practice and saves money by automating several time-consuming tasks. One such automation is called cloned notes. When done properly, carrying over notes from a previous visit can be a great time saver. However, these notes must be checked and edited to make them pertinent to the current visit to ensure that your EHR is coding to the correct level of service.
For more information on cloned notes, read “The Good and Bad of Cloned Notes” in The Rheumatologist.
Understanding coding and documentation guidelines is your best defense against common—but potentially costly—mistakes. If you need assistance with coding and reimbursement, contact the ACR’s practice management department at (404) 633-3777 or practice @rheumatology.org, or join the ACR coding list serve at www.rheumatology.org/membership and post your questions online.