# Nurse practitioner and incident to



## carolanntomko (Nov 20, 2013)

We are going to hire a nurse practitioner. Our oncology doctor is going to see patients in our outpatient clinic for E&M visits in addition to their chemotherapy sessions. I have a question about if the nurse practitioner sees the patient. Do we bill under the physicians NPI or under the nurse practitioner? And, if a full E&M service is performed on the day of chemotherapy administration, is that a separately allowable charge? Thanks. New to chemo coding.


----------



## debkidcks (Nov 20, 2013)

Incident-to billing is done under the physician's NPI.  It's important to remember that incident-to is for follow-up visits only, and it can't be for a new problem.  If the patient hasn't been seen by the physician before or has a new problem, the billing is then done under the nurse practitioner's NPI.

In our infectious disease practice, we provide in-office antibiotic infusion therapy so we bill drug and infusion codes, and the patients do sometimes see the physician on the same day as an infusion.  In these instances, the E&M charge is separately payable as long as a full visit was completed and documented.  A 25 modifier must be billed with the E&M charge.  

Someone who does chemo billing can correct me if chemo rules are different from infusion (insurance carriers have often compared our infusion billing to chemo when it comes to questions like this), but you should be able to bill the E&M with a 25 modifier.  Note - A 99211 cannot be billed, with or without a 25 modifier, if on the same DOS as the infusion (chemo).  It will be denied as content to the infusion (chemo).

Hope this helps.


----------



## OCD_coder (Nov 21, 2013)

debkidcks is correct, if the E&M service is documented correctly and supports a separate evaluation from the infusion services.  Modifier 25 would be correct as the infusion CPT codes have a XXX global status code.  Per the NCCI Manual, codes with XXX global status codes are exempt from the Mod-25 global rules, meaning there is no E&M services included as part of the global service of the infusion codes.

Chemo patients must be evaluated prior to chemo given each and every visit, typically labwork is checked to see how the chemo is affecting their organ systems, etc.  Most cancer patients have multiple conditions managed constantly due to the effects of the chemo; not simply treating cancer with chemo alone and will potentially support medical necessity of the E&M visit.  Documentation of the clinical course and treatment plans for all conditions is important.

Good question and good answer to both Coders!


----------



## maryann1224@bellsouth.net (Nov 22, 2013)

*another Nurse Practicioner question*

We are a cardiology office and if our ARNP sees an established patient in the hospital for a consult for AFIB; however this patient hasnt been treated for this AFIB for several years, would this be considered a new problem, or length of time does not matter?

What are the guidelines for our ARNP to do a consult or follow up in the hospital, does our Dr need to do a physical exam on each of these or just co sign on the ARNP note?

Any help is greatly appreciated.


----------



## rubisaavedra (Nov 29, 2013)

*New PA in practice*

Hello, I have a doctor who just hired a PA for assisting in surgeries and need help with coding..I understand that for PA we will use modifier AS whenever a surgery is performed under direct supervision from the dr...the manager also instructed me to use the dr npi when billing for the PA...does the dr npi stay in fields 24j and 33 ? 
Any help would be appreciated! Thanks


----------



## OCD_coder (Nov 30, 2013)

Maryann,

If your ARNP sees the patient in the office, she can certainly see patients that haven't been seen in a while and bill for their services with the appropriate New or Est E&M code.  But in order to meet Incident To rules the supervising provider will also need to see the patient on the same day and initiate a treatment plan.  If the provider does not document his portion of the service in a face-to-face content with the patient, the service is billed under the mid-level's NPI at a reduced rate.

In regards to the Inpatient visits, these visits fall under the split/shared rules and Incident To rules do not apply, ever.  The mid-level and provider will both need to perform portions of a face-to-face service and document what they do in detail in order to bill under the supervising providers NPI#.  A signature alone is never acceptable to bill under the supervising providers NPI#.

AS modifier
Unless the carrier specifically states bill assistant surgeon under the NPI# of the surgeon, which I have never encountered, always bill under the PA's NPI#.  They will more than likely get denied as a duplicate with a surgeon's NPI# and raise potential red-flags for additional scrutiny.


----------



## rubisaavedra (Dec 3, 2013)

Hello OCD, was that response just for Maryann? I hear different things, and I do agree that billing under MD npi on both rendering provider and billing provider npi calls for trouble..where can I go to show manager we need to indicate PA npi on 24j and MD npi as billing provider only..I was also told PA is on payroll so I think that's why manager states we can use MD info on both rendering/billing provider fields along with mod AS
Thanks again!


----------



## mitchellde (Dec 3, 2013)

rubisaavedra said:


> Hello OCD, was that response just for Maryann? I hear different things, and I do agree that billing under MD npi on both rendering provider and billing provider npi calls for trouble..where can I go to show manager we need to indicate PA npi on 24j and MD npi as billing provider only..I was also told PA is on payroll so I think that's why manager states we can use MD info on both rendering/billing provider fields along with mod AS
> Thanks again!



If you look in the MCM  inicident to is covered along with detail on whose NPI goes in which field.  There was a transmittal issued April 2004 regarding the appropriate way to complete the claim for incident to billing.


----------



## rubisaavedra (Dec 5, 2013)

Thank you! i truly appreciate your input!


----------



## akshar13 (Mar 31, 2014)

*IDCC infusions*



debkidcks said:


> Incident-to billing is done under the physician's NPI.  It's important to remember that incident-to is for follow-up visits only, and it can't be for a new problem.  If the patient hasn't been seen by the physician before or has a new problem, the billing is then done under the nurse practitioner's NPI.
> 
> In our infectious disease practice, we provide in-office antibiotic infusion therapy so we bill drug and infusion codes, and the patients do sometimes see the physician on the same day as an infusion.  In these instances, the E&M charge is separately payable as long as a full visit was completed and documented.  A 25 modifier must be billed with the E&M charge.
> 
> ...



Hello! Debkidcks,

Our Infectious Disease practice will start giving in-office antibiotic infusion therapy  soon. According to my understanding if only drugs are being infused by NP, then we will bill infusion/drug and supply codes with 99211/25 under NP and if PA or Physician see the patient on same day of the infusion, then will bill infusion/drug and supply codes with E/M code (99213 and up/25) under PA or Physician.  Please advise if this is correct. Not then please correct me.


----------



## mitchellde (Mar 31, 2014)

You cannot charge a visit level of any type when the patient presents to the office for a predertmined service.  The administration codes includes the evaluation of the patient necessary to complete the procedure. IF the patient has new complaints or the provider discovers something new then you may have the justification for the visit level.  Youn can never use a 99211 for an infusion.


----------



## vgaurav86 (Aug 10, 2015)

*Billing for NP(Incident to and Direct)*

hey guys we are hiring a NP and i am trying to find out as to what is the correct way to bill for "incident to" and "direct' billing.
1.Do we need to use some modifier if billing for incident to encounter?
2.Whose NPI we put on block 17 and block 24 (Provider's or Nurse practitioners)
3.Can a locum physician supervise the nurse practitioner?

Thanks a ton for help.


----------

