# Proper Billing of Incident To



## kwhite2008 (May 27, 2014)

The hot topic of "Incident To" has recently come up with our oganization. 
Our coding department is stating that if a NP/PA sees a patient and needs to alter the previous treatment plan set by the doctor, that provider has to come into the suite and see the patient. If that is not done then "Incident To" cannot be billed. 
Our providers have other concerns as well. 
We have looked on the CMS website and of course there is a lot of information but, it is overwhelming and not cut and dry. 
In more simple terms, can someone break down when billing "Incident To" is and is not appropriate?
Any backup documentation from CMS is greatly appreciated as well.

Thanks!


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## mitchellde (May 27, 2014)

Per the CMS MCM, I believe it is section 2050, to bill incident to
- the physician must have already examined the patient in a previous encounter and must have a written plan of care that the PA/NP is following.
- the physician you are billing under must be the defined office suite area at the time the patient is being seen.
- the physician you are billing under can be any physician in the practice as long as they are in the same specialty as the ordering provider
- The PA / NP must be an employee of the provider
To boil it down simply it cannot be incident to if this is a new patient, a new problem in an established patient, any visit where the billing provider is not in the office, or if there is no plan of care in the previous notes to be followed.
Therefore the coding department is correct, if the PA changes or wants to change the existing treatment plan or the patient has a new problem then the physician must face to face with the patient and write their own note, this is then a shared encounter and can be billed under the physician.
Look up transmittal 1764


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## kwhite2008 (May 28, 2014)

Thank you for the information.


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## LMBENHOFF (Jun 4, 2014)

*Hospital Initial Patient Split/Shared?*

I understand the Incident-to rules in the office setting, but how does this rule apply in the inpatient setting?  Can an initial hospital visit on a new or established patient and or new problem ever be split/shared?  I can't find any definite guidelines on this...


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## dclark7 (Jun 4, 2014)

You can find the information in the Medicare Claims Processing Manual 100-04, Chapter 12, Section 30.6.1.    http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf


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## LMBENHOFF (Jun 4, 2014)

*Initial Inpatient Encounter*

Thank you for your reply.  I have read Chapter 12 countless times, and again, no specific mention of initial encounters in the inpatient hospital setting that give a clear view on CMS's stand on Split/Shared visits on 99221-99223 since the elimination of consult codes in 2010.  I've heard of RAC's targeting for these types of visits in the Chicago area for NP's and MD's split/sharing initial visits as the plan of care must be established in order to be billed incident-to/split shared in office or hospital setting?  Please share your thoughts!?


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## mhstrauss (Jun 4, 2014)

LMBENHOFF said:


> Thank you for your reply.  I have read Chapter 12 countless times, and again, no specific mention of initial encounters in the inpatient hospital setting that give a clear view on CMS's stand on Split/Shared visits on 99221-99223 since the elimination of consult codes in 2010.  I've heard of RAC's targeting for these types of visits in the Chicago area for NP's and MD's split/sharing initial visits as the plan of care must be established in order to be billed incident-to/split shared in office or hospital setting?  Please share your thoughts!?



I've never found specific instruction on 99221-99223 for Split/Shared Visits directly from CMS either.  Try your MAC's website.  Mine (Novitas) only has a short listing of services that CANNOT be Split/Shared...Critical Care; Procedure; and any E/M performed in a SNF.  From what I'm reading, other than those 3, anything goes.

Here's a link to the Novitas site; I'm not sure who your MAC is, but this will give you an idea of what type of guidance may be available.

http://www.novitas-solutions.com/we...es%2FMedicareJH&_adf.ctrl-state=4rldpv7xf_231

Hope this helps!


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## mitchellde (Jun 4, 2014)

Transmittal 1776 has a section on slip/shared visits.  You cannot bill incident to in the inpatient setting, you can bill as a split encounter if the provider physicially examines the patient on the same day and write a separate note for the encounter.


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## LMBENHOFF (Jun 5, 2014)

*Split/Shared Initial Inpatient Services*

Thank you ladies for your input.  I've previously read the transmittal posted above and again, it does not specify initial inpatient visits but instead states that "Inpatient Consultations" may not be split/shared- this policy has not been updated since the 2010 No Consult rule by Medicare.  Please send me any other thoughts you may have on this slippery issue.


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## RebeccaCross* (Jun 5, 2014)

*Hospital Inpatient/Outpatient/Emergency Department Setting*

When a *hospital inpatient/hospital outpatient or emergency department E/M* is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's UPIN/PIN number. However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient's medical record) then the service may only be billed under the NPP's UPIN/PIN. Payment will be made at the appropriate physician fee schedule rate based on the UPIN/PIN entered on the claim

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

*(30.6)*


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