Coding and Billing Rules in 2016: Out With the Old, In With the New


Incident-to rules and advance care planning top the list of changes.

Fam Pract Manag. 2016 Jan-Feb;23(1):14-16.

Author disclosures: no relevant financial affiliations disclosed.

Published online ahead of print on Dec. 3, 2015.

Jan. 1 ushers in a new Medicare physician fee schedule and regulations, as well as a new edition of CPT. The 2016 versions clarify Medicare's “incident-to” rules and formalize codes and billing rules for Medicare's new advance care planning benefit, among other changes. Here is a summary of the changes most likely to affect family physicians.

“Incident-to” services

First, the Centers for Medicare & Medicaid Services (CMS) has amended its incident-to regulations to clarify that the physician or other practitioner who bills for incident-to services must be the same person who directly supervised the ancillary personnel who provided the services. The direct supervision requirement for incident-to services has not changed – the physician must be present in the office suite (but not the exam room) and immediately available to furnish assistance and direction throughout the performance of the service.

This does not mean that the billing/supervising physician also has to be the one who initiated the original care plan or service upon which the incident-to service is based. Under the clarified regulations, scenarios like the following are acceptable: Dr. A treats Mrs. Jones on Monday, initiating a plan of care and asking her to return in one week for follow-up with the nurse. Dr. A is on vacation when the patient returns and his partner, Dr. B, directly supervises the nurse visit and bills for the service under his own provider number.

When incident-to services are provided, practices will need to decide which physician qualifies as the supervising physician. Although claims don't identify that services were provided incident to a physician's care, medical record documentation should clearly name the supervising physician.

Note that services and supplies provided incident to transitional care management and chronic care management services remain an exception to the direct supervision requirement. These can continue to be provided under the general supervision of the physician (or other practitioner). General supervision means the service is furnished under the physician's overall direction and control, but the physician's presence in the office suite is not required.

CMS also amended its regulations to clarify that ancillary personnel are prohibited from providing incident-to services if they have been excluded from Medicare, Medicaid, or any other federally funded health care programs by the Office of Inspector General or have had their Medicare enrollment revoked for any reason. Such individuals are technically prohibited from providing services to Medicare beneficiaries, but CMS makes it explicit in this case.

Advance care planning

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About the Author

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Kent Moore is senior strategist for physician payment for the American Academy of Family Physicians (AAFP) and is a contributing editor to Family Practice Management....

Barbara Hays is coding and compliance strategist for the AAFP.

Author disclosures: no relevant financial affiliations disclosed.


Copyright © 2016 by the American Academy of Family Physicians.
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