# Using Time stmt, billing 'incident to'



## dtricia (Jul 17, 2013)

I believe it is perfectly ok for NP to use  time  when billing incident to. Manager says only the billing provider can base billing on time.

A NP and MD are both qualified health care professionals.
I need more documentation . I have provided Ch 12 MDCR Claims Processing Manual, but manager interprets the sentence that 'counseling by other staff is not considered in selecting the appropriate level of service' to include NP. To me NP is on a par with MD in this circumstance.

Tricia D


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## rhndyts (Jul 17, 2013)

http://www.aapa.org/uploadedFiles/c...bursement/Resource_Items/Incident-to-2012.pdf

Hope this helps.


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## LLovett (Jul 17, 2013)

*Interesting*

I have never ran into this scenario before. My first thought is does it meet incident to requirements. If the NP is truly working incident to then there should be nothing changed or added so I am having a hard time seeing where they would get into a situation that time would be more beneficial than key components.

While I can't think of a concrete reason why it wouldn't be covered, I also can't think of a plausible scenario either. I would love to see more detail on your situation.

The issue that keeps sticking in my head is critical care. It can't be incident to or split/shared but 2 providers in the same group of the same specialty are considered the same person so their time can be added together and billed as one. Obviously there is a little more to it but the parallel I am making is that this is a time based service and one of the catches is same specialty in order to be considered the same. NPs are a separate specialty in the eyes of CMS.

Just my thoughts,

Laura, CPC, CPMA, CEMC


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## RebeccaWoodward* (Jul 17, 2013)

dtricia said:


> I believe it is perfectly ok for NP to use  time  when billing incident to. Manager says only the billing provider can base billing on time.
> 
> A NP and MD are both qualified health care professionals.
> I need more documentation . I have provided Ch 12 MDCR Claims Processing Manual, but manager interprets the sentence that 'counseling by other staff is not considered in selecting the appropriate level of service' to include NP. To me NP is on a par with MD in this circumstance.
> ...



I haven't encountered this scenario, either.  Time based billing is spent in counseling and coordination of care.  If your following "incident to" guidelines, then this would negate the physicians established plan of care.  "Incident to" is following the plan already established by the physician.  In my opinion, you have one of two options, the NPP delegates this encounter back to the physician or the NPP bills this "counseling and coordination of care" under the NPP's provider number (with proper documentation demonstrating the need for this counseling and coordination of care).

"It’s also important to note that, when billing incident-to, nonphysician providers cannot be reimbursed for consultations or time-based E/M services when more than 50 percent of the service is counseling or coordination of care (according to the Carrier’s Manual, the only time that counts is face-to-face time between the physician and the patient in the office). However, certain nonphysician providers can be reimbursed for these services when billing on their own provider numbers"

http://www.aafp.org/fpm/2001/1100/p23.html

Obviously, CMS no longer recognizes consultation codes, but this article does address "incident to" and time-based billing.

Medicare Chpt 12:

In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. *The code used depends upon the physician service provided.*


--My two cents~


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## dtricia (Jul 17, 2013)

*NP 'Incident to' billing time*

In oncology there are often times when the NP counsels patients about the careplan, what to expect, disease process, medication compliance....no end
Tricia D, RHIT, CPC, CCS-P


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## dtricia (Jul 17, 2013)

*Incident To, time statement*

Rebecca, what is the source of the underlined statement you provided?

Tricia D


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## RebeccaWoodward* (Jul 18, 2013)

dtricia said:


> Rebecca, what is the source of the underlined statement you provided?
> 
> Tricia D



The link was provided...American Academy of Family Physicians


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## MnTwins29 (Jul 18, 2013)

"In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the *physician* only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided."   From Chapter 12 of the Medicare Claims manual as provided by Rebecca.

I have a slightly different interpretation of this statement than Rebecca.  Where I added the bold type, I don't interpret that to be only a PHYSICIAN.  I belive it can also include "other qualified health care professionals" as used in the code descriptions that were added to E/M codes in 2013.   These "other qualified health care professionals", i.e an NP, are the ones providing the service.   Also keep in mind that incident to services are provided "as if" the physican was providing it.  Therefore, if the NPP is providing the service "as if" the physician was, and there is face-to-face time with the NPP, that counts "as if" it were face-to-face time with the physician.   

While I have not seen an example of a visit that is mostly counseling or coordination of care that could be incident to, I can certainly see it in oncology settings as mentioned in a previous post.  I can also see this in this type of scenario: say the patient visits with the NP/PA and they spend most of the time discussing risks and benefits of the medications that were prescribed by the physician when he created the current treatment plan.  The NP/PA is not changing this, is not treating a new condition, and is following the plan developed by the physician.   That would, IMO, qualify as incident to and use time for the code assignment.

My $0.02...


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## dtricia (Jul 18, 2013)

*NPs, Time,Incident To*

That is exactly my interpretation of the Manual guidelines. The use of word PHYSICIAN equates to other billing health care providers such as Nurse Practioner. It cannot be taken that literally.
Thanks for taking time to respond (and agree!!)
Tricia D


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## RebeccaWoodward* (Jul 18, 2013)

Doing some research and speaking to others, I tend to agree with the previous posts.  I can see where there may be an encounter that is following the established plan of care by the physician.  The encounter involved with the NPP could be time spent following the course of treatment.

Good question.  Thanks for the post.  Made me think...


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## OCD_coder (Aug 25, 2013)

I know this is a late reply posting, but I must stress caution with the interpretation above.  

Time documentation does not apply towards incident to billing.  This has been elaborated by many MACS, even if your MAC doesn't specifically state it the interpretation of the guidelines here are concerning.

Your manager is 100% correct regarding...._Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service.,  but you are also correct that a NPP is considered a provider as much as a physician when it comes to billing.  A physician or other healthcare provider can bill based on time documentation, just not as incident to under the supervising physicians NPI #. This means that the provider doing the face to face work, is the person the claim needs to be billed under their own NPI #.  If the PHYSICIAN did not perform face to face work themselves, then the NPP needs to bill under their own NPI number.  

CMS Guidelines on Time Documentation:You must appropriately and sufficiently document in the medical record that you personally furnished the direct face-to-face time with the patient specified in the CPT code definitions. Make sure that you document the start and end times of the visit, along with the date of service.  I have heard this statement spoken many times in CMS webinars, but this is the only place I have seen it written.

http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/MM5972.pdf

I have billed oncology education encounters for years and they are billed under the NPI's of the NPP's even though it is part of the treatment plan of the oncologist.  The billing staff could get a physician in trouble by billing incident to based on an NPP's time documentation and it's just not worth the little extra % to the practice._


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## MnTwins29 (Aug 26, 2013)

@OCD_Coder:   Did you attach the correct MLN link?  The one in your message is about prolonged services.


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## RebeccaWoodward* (Aug 27, 2013)

OCD_coder said:


> I know this is a late reply posting, but I must stress caution with the interpretation above.
> 
> Time documentation does not apply towards incident to billing.  This has been elaborated by many MACS, even if your MAC doesn't specifically state it the interpretation of the guidelines here are concerning.
> 
> ...


_

While I appreciate your post, I don't think ANYONE here is twisting the rules! Rather big assumption..._


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