# Incident to



## pattis9 (Oct 15, 2008)

Could someone help with a debate in my office.  I've tried to explain that a Physican must be in our office suite while a NP is seeing patients in order to allow us to bill services correctly.  However, I continue to hear that state law  doesnt require a physican in the office but as long as he/she is accessible to the NP.
Could someone assist me with this debate as I know CMS or Federal quidelines override state requirements?


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## machi57 (Oct 15, 2008)

*Incident To*

My question is also regarding Incident To.
Dr sees pt today, pt comes back in a few days
for a penicillion injection ordered at the 1st visit.
RN administers injection, DR is "readily available".
RN wants to bill 99211, 90772 and J0580.
Can she bill all 3?  Her documentation really only
supports the injection, but according to CMS 
99211 and 90772 can't be billed together?

Rose


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## s9uccess (Oct 15, 2008)

pattis9 said:


> Could someone help with a debate in my office.  I've tried to explain that a Physican must be in our office suite while a NP is seeing patients in order to allow us to bill services correctly.  However, I continue to hear that state law  doesnt require a physican in the office but as long as he/she is accessible to the NP.
> Could someone assist me with this debate as I know CMS or Federal quidelines override state requirements?


You are correct about Medicares guidelines.  For incident to rules the physician does have to be in the suite with the NP/PA. In addition a physician needs to have seen the patient initially for that diagnosis.  If the NP/PA diagnosed the patient initially then the visit cannot be considered incident to.

 You can find this in detail on the CMS website.  Below i have copied the passage pertaining to this.  Here is the website  http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0441.pdf


To qualify as “incident to,” services must be part of your patient’s normal course of treatment, during which
a physician personally performed an initial service and remains actively involved in the course of
treatment. You do not have to be physically present in the patient’s treatment room while these services
are provided, but you must provide direct supervision, that is, you must be present in the office suite to
render assistance, if necessary.


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## s9uccess (Oct 15, 2008)

pattis9 said:


> Could someone help with a debate in my office.  I've tried to explain that a Physican must be in our office suite while a NP is seeing patients in order to allow us to bill services correctly.  However, I continue to hear that state law  doesnt require a physican in the office but as long as he/she is accessible to the NP.
> Could someone assist me with this debate as I know CMS or Federal quidelines override state requirements?


Forgot to mention that for commercial insurances this can vary.  I have found that they don't necessarily follow incident to rules.  For example we have been told that although Regence follows Medicare guidelines they want NP/PA billed in their own.


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## efrohna (Oct 16, 2008)

machi57 said:


> My question is also regarding Incident To.
> Dr sees pt today, pt comes back in a few days
> for a penicillion injection ordered at the 1st visit.
> RN administers injection, DR is "readily available".
> ...



Rose, if the patient came back for an injection ONLY, then that is what should be billed (90772 & J0580).  What was the medical necessity for the 99211?


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## FTessaBartels (Oct 16, 2008)

*Forget Incident To*

Forget "Incident to" for a minute ... why aren't the NP's services coded separately?

In some of our specialties the NP has his/her own clinic and handles everything, including new patients. We code and bill under the NP's name. 


F Tessa Bartels, CPC, CPC-E/M


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## LLovett (Oct 16, 2008)

The reimbursement rate is higher when they are billed incident to. For Medicare they reimburse at 100% of the physician fee schedule when billed  incident to but only 85% when billed non incident to. 


Laura, CPC


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## FTessaBartels (Oct 17, 2008)

*Please tell me ...*



katmryn78 said:


> The reimbursement rate is higher when they are billed incident to. For Medicare they reimburse at 100% of the physician fee schedule when billed  incident to but only 85% when billed non incident to.
> 
> 
> Laura, CPC



Please tell me you are *NOT* coding based on how you'll be reimbursed vs coding based on the service provided!

F Tessa Bartels, CPC, CPC-E/M


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## ARCPC9491 (Oct 20, 2008)

Nothing is 'coded' differently with incident to - it's a physician's or practice's decision if they wish to utilize "incident to" or have the NP's seperately enroll.  Not a coders decision.

From my personal experience, incident to is just a big pain and trying to get everyone on the same page with documentation and following the guidelines is pretty difficult. Our NP's and PA's are seperately enrolled, so yes they take the 15% cut, but in most cases, it's worth it.

I recently did an audit at a practice that "thought" they were billing incident to correctly - long story short, they had to refund Medicare over $100K.


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## LLovett (Oct 20, 2008)

*Response to FTessaBartels*

Please read what was said before you question my ethics in the future. I would greatly appreciate that. I responded to why people would bill NP's incident to. That was not a coding question, that is a billing question. 

Laura, CPC


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## FTessaBartels (Oct 20, 2008)

*Sorry*

You're right, Laura, I misinterpreted what you were saying in your earlier response. 

Our NPs and PAs are separately enrolled, but we sometimes bill "incident to" when it's appropriate and all documentation supports. 

As AR pointed out, the guidelines are detailed and specific and it is easy to err resulting in significant penalty to the practice once audited. 

F Tessa Bartels, CPC, CPC-E/M


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## j9ok2010 (Nov 9, 2008)

SA Modifier

Does anyone use the SA modifier when  billing for a NP as an incident-to service ?

J9


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