Key Takeaways

• NPI attribution confers personal ownership of each claim, making operative notes and E/M documentation central evidence when coding diverges from services actually rendered.
• Incident-to requires a physician’s initial evaluation for that condition plus an established plan of care and qualifying direct supervision; otherwise repeated follow-ups become false claims, regardless of onsite presence.
• Mohs billing is invalid if histopathologic interpretation is performed by anyone other than the excising surgeon, and post-Mohs closures must satisfy incident-to supervision when billed under the surgeon’s NPI.
• Upcoding linear repairs as flaps, inflating defect sizes, or appending modifier 25 without a separately identifiable E/M service are common enforcement targets with substantial settlement precedent.
• Qui tam enforcement frequently originates from internal staff, with meaningful relator awards and strong anti-retaliation remedies; “reckless disregard” includes choosing not to understand billing practices.

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In this edition of The Practice Playbook, learn incident-to rules, Mohs coding limits, NPI liability, and how audits and whistleblowers trigger FCA cases.

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