When a nonphysician practitioner (NPP) sees a Medicare patient at your practice, you can typically plan to collect a reduced rate compared to what a physician would receive for the same service. But one way you can avoid accepting 15% less pay for the same service is by utilizing incident to billing — if you know the rules.
If a physician develops the established patient’s plan of care and an NPP employed by the practice sees that patient in the office for follow-up, you can typically bill the service incident to and collect the full fee. The physician must be on-site and immediately available if needed during the encounter, and you should include that detail in your documentation.
Still confused? It may help to look at three examples of incident to billing to see when it’s allowable and when it isn’t.
1. PA Sees New Patient
Example 1: Suppose a physician’s assistant (PA) sees a new patient at your office. The physician does not see the patient, but does review the note and sign off that they agree with the findings and the treatment plan.
Solution 1: In this situation, you absolutely cannot report this visit under the physician’s NPI, since it’s a new patient, the physician didn’t create the plan of care, and the physician didn’t see the patient. It therefore does not support the rules under incident to billing.
Instead, you must submit this claim using the NPI of the PA. You’ll collect 85% of the fee schedule amount for the service.
2. NP Sees Established Patient
Example 2: An established patient with hypertension sees the doctor during the first week of September and his blood pressure is elevated. The doctor adjusts the patient’s blood pressure medication prescription and asks the patient to return a week later for a blood pressure check.
During the second week of September, the patient returns and sees the nurse practitioner (NP), who takes the patient’s blood pressure, talks to her about side effects of the new dosage and asks about how she’s feeling. The NP performs and documents an exam. The doctor is in the office suite during the visit.
Solution 2: You can report this visit under incident to, since it meets the guidelines of the billing rules. Therefore, assuming the documentation is solid, you can collect 100% of the fee schedule amount for this visit.
3. NP Sees Patient With New Problem
Example 3: An established patient with congestive heart failure (CHF) presents for his medical management appointment with the nurse practitioner. The established plan of care for the CHF is reviewed, and medication refills are provided. The patient then says he has a new complaint of shoulder pain. The nurse practitioner evaluates the patient’s shoulder and orders X-rays.
Solution 3: Although this visit started as a straightforward incident to billing situation, it evolved into a visit that cannot be billed incident to, because there is no established plan of care for the shoulder pain. Therefore, the NP should bill this visit under her own NPI and not under the doctor’s NPI. You’ll collect 85% of the fee schedule amount for the visit.
Incident-to can be mired in complex rules and policies. Don’t leave anything to chance — let expert Jennifer Swindle RHIT, CCS, CCS-P, CDIP, CPC, CIC, CPMA, CEMC, CFPC provide you with the strategies you need to master this complicated topic. During her one-hour online training event, NPP Incident-To: Use Supervision to Maximize Your Reimbursement, Jennifer will walk you through the intricacies of incident-to coding and billing so you’ll collect all that you’re due, every time. Register today!
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