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Response to 'Incident to Billing'

In Response to ‘Incident to Billing’ | Some Clarification is Needed

Dermatology News recently published a letter by Brett Coldiron, MD seeking to clarify Medicare’s “incident to” billing when working with PAs in the office. We can agree that all dermatologists who work with PAs, the PAs themselves, and the billing staff need to fully understand Medicare “incident to” rules to maximize revenue and to avoid billing fraudulently. Dr. Coldiron’s examples include a new patient and a follow up patient who focuses on only the original complaint. The reality is that follow up patients rarely stick to the original complaint. Any new problem requires physician involvement to be able to bill “incident to” and to collect 100% of the physicians Medicare rates vs. 85% if the PA bills using their own NPI. Most of the time coordinating the physician and PA to see the patient is so inefficient that the 15% gained by billing “incident to” is lost in productivity. In his example of the new patient, the rules for requiring the physician to initiate the course of treatment are not followed. By definition a new patient has not yet been evaluated, diagnosed and had a treatment plan developed by the physician. So it is not appropriate for new patients to be seen by a PA and have the service billed “incident to” under the physician’s NPI. A new patient seen by the PA, even when the physician is involved and participates in the diagnosis, development and implementation of a treatment plan, is most appropriately billed under the PA’s own NPI. Dr. Coldiron seems to suggest that no dermatologist with a supervised PA would give up 15% of the Medicare fee. He implies that dermatologists must be confused by these rules or that they are not properly supervising their PAs. That is not fair to dermatologists who utilize PAs, the patients, or the PAs. Access to care and efficiency is worth far more than the 15% and it is not all about the money. A more in depth and accurate review of “incident to” billing guidelines, from the American Academy of PAs, follows:

“Incident to” is a Medicare billing provision that allows PAs to bill Medicare under the physician’s NPI number, only if Medicare’s strict criteria for “incident to” billing are met:

  • Services are provided in a physician’s office or physician’s clinic;
  • Physician sees Medicare patient on initial visit, establishes a diagnosis and treatment plan. PA sees patient on follow-up visit;
  • For established Medicare patients with a new problem, the physician sees the patient first for the new problem, establishes a diagnosis and treatment plan, PA sees patient on follow-up visit;
  • A physician is on site, within the suite of offices, when the patient is seen by the PA;
  • Services are within the PA’s state law scope of practice;
  • The PA represents a direct financial expense to the physician billing (W2 or leased employee, or independent contractor); and
  • The physician must continue to see the patient at a frequency that reflects ongoing management of the patient’s care.

If all of the above criteria are met, you may bill Medicare under the physician’s NPI with reimbursement at 100%. If any of the bulleted criteria are not met, bill Medicare under the PA’s NPI with reimbursement at 85%.

Even more disturbing is the continued criticism of our profession, a majority of which is derived from incorrect assumptions. PAs, in all specialties, work in conjunction with their collaborating physicians to provide quality and efficient healthcare to patients who would otherwise have lengthy waits for diagnosis and treatment. Dermatology offices where PAs are employed should always be transparent about the name and qualifications of the provider being seen by the patient, both during the time of appointment booking and with appointment reminders. PAs in many states are required to wear an identifying name badge or clothing to clearly represent themselves, and it is common knowledge in appropriate bedside manner to introduce yourself upon greeting the patient. Clearly, these protocols leave little room for confusion about who actually saw the patient as Dr. Coldiron suggests. Additionally, there is no data supporting his assumption that the increase in skin biopsies seen in Medicare data over the past ten years is due to inappropriate biopsy selection by PAs. A recent study published in the Annals of Internal Medicine sought to compare advanced practice clinicians (PAs and NPs) to physicians directly with regard to ordering potentially guideline-discordant and “low-value” health services. Low-value health services are defined as patient care that typically portends a greater probability of harm than benefit, which has important implications for the quality and efficiency of care delivery in the U.S. health care system. The results showed that PAs, NPs, and physicians in both office and hospital-based settings provided equivalent amounts of guideline-discordant low-value care. The continued barrage of inaccurate claims regarding dermatology PA practice is beyond disappointing. The SDPA will continue to work hard to ensure that our members have access to the education and resources they need to best serve their communities and patients.


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