# Auditing incident to



## espforu

We recently have started employing Nurse Practitioners and PA's.  I am trying to make sure our records are correctly showing when a service is a "incident to". Our providers are signing off on the charts as well, but is this sufficient? I would think they need some type of wording or proof of how they are involved in the patient care.  Our records are electronic.  

Any advice?  I have been trying to look on the CMS website but everything is so vague when it comes to incident to.  

Thank you in advance.  

Kim


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## mdoyle53

Incident to is very simple (using the CMS guidelines):

1. Patient is in a treatment plan
2. Provider is practicing within the state guidelines for their credential
3. Provider is classified as an employee
4. MD is in the suite - this means in the office where the services are being performed - ie - actually in the office
5.  Service is in the outpatient office setting


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## kagal0816@verizon.net

Michael - Like Kim, I find the guidelines vague.  For instance, what is the definition of a treatment plan?  Example - Chronic asthmatic seen as a new patient by physician.  Patient follow up is scheduled with PA and subsequent quarterly medication checks are scheduled with the PA.  The patient's asthma is controlled on the current regime of medication.  When would the PA stop functioning under the initial treatment plan?  On condition exacerbation only?  This is question that frequently arises among the providers.  

Any input or resources?  They would be much appreciated.  Thanks, Karen


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## MnTwins29

kagal0816@verizon.net said:


> Michael - Like Kim, I find the guidelines vague.  For instance, what is the definition of a treatment plan?  Example - Chronic asthmatic seen as a new patient by physician.  Patient follow up is scheduled with PA and subsequent quarterly medication checks are scheduled with the PA.  The patient's asthma is controlled on the current regime of medication.  When would the PA stop functioning under the initial treatment plan?  On condition exacerbation only?  This is question that frequently arises among the providers.
> 
> Any input or resources?  They would be much appreciated.  Thanks, Karen



In your example, when the MD saw the new patient, what treatment plan did he or she develop?   Was it to continue the current medication regiment and monitor?  Was it a new medication?  Any other tests or treatment advised?   Whatever this plan of treatment was, in order to bill the PA visits as incident-to, these subsequent visits must follow this plan for this condition.   If the PA treats a new problem in addition fo the asthma, then the visit cannot be billed as incident-to.

I agree that the CMS guidelines are pretty simple to understand (a rarity at CMS! )    Try this for starters, paying attention to section 20:

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


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## kagal0816@verizon.net

*Treatment Plan - Incident to*

Thank You for your response.  I will answer your questions using this hypothetical scenario:
1.  MD developed treatment plan which included medications.  
2.  PA did follow this plan in subsequent visits.
3.  Patient did not experience exacerabation of symptoms, no new problems or issues.  Again, medication was refilled by PA, but initial medication plan as written by MD on initial visit was still being followed.  (Same medication, same dosing)
4.  Plan is still effective for patient's management, with no new conditions, issues, or complaints referable to their asthma condition.

So, basically if there are no changes whatsoever, patient is stable, can the billing of incident to services continue for one year, two years, or until the patient's condition worsens or their is an associated problem such as a URI?  Should the patient be seen bi-annually, or continue with the PA incident to?

Obviously, this issue has been a thorn in my side, and I am looking for resources that demonstrate this type of scenario for my providers.  Thanks again,

Karen Gallagher, CPC, COSC


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## MnTwins29

kagal0816@verizon.net said:


> Thank You for your response.  I will answer your questions using this hypothetical scenario:
> 1.  MD developed treatment plan which included medications.
> 2.  PA did follow this plan in subsequent visits.
> 3.  Patient did not experience exacerabation of symptoms, no new problems or issues.  Again, medication was refilled by PA, but initial medication plan as written by MD on initial visit was still being followed.  (Same medication, same dosing)
> 4.  Plan is still effective for patient's management, with no new conditions, issues, or complaints referable to their asthma condition.
> 
> So, basically if there are no changes whatsoever, patient is stable, can the billing of incident to services continue for one year, two years, or until the patient's condition worsens or their is an associated problem such as a URI?  Should the patient be seen bi-annually, or continue with the PA incident to?
> 
> Obviously, this issue has been a thorn in my side, and I am looking for resources that demonstrate this type of scenario for my providers.  Thanks again,
> 
> Karen Gallagher, CPC, COSC



There is no "time limit" for incident-to.   As long as the initial treatment plan was developed by the MD and the PA is continuing that plan, it can be billed as incident-to.   Refills by the PA are okay, as this shows there is no change in the treatment plan.    If there is exacerbation, then anything new in the treatment plan (change of meds, etc.) would have to be documented by the MD.  If not, then bill under the PA.   Same if any of the other associated conditions are treated by the PA, such as a URI in your example, because to treat this may require a different path than the original treatment plan.


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## kagal0816@verizon.net

*Thanks*

Thanks, Lance.  We have a large practice and there are cases where a physician assistant has been seeing patients for as long as two years.  Again, thank you.


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## kparkhurst

I would caution on using incident to for 2 years without the patient being seen periodically by the supervising physician. It all depends on how often the patient is seen. Somewhere in your compliance plan, you should state your practice's guidelines on using incident to. Example - Patient is seen every
 4th/5th visit by the supervising physician to review treatment plan. Otherwise, this could have the appearance that the mid-level has taken over management of the problem.


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## kagal0816@verizon.net

*Incident To*

Thank you for your input.  Our Compliance Plan does state every third visit.  For those who do not follow the internal rules, I was looking for something that would be considered "more concrete" to bolster 100% compliance.  Thanks again, Karen


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## kbartrom

1) Established patient with established treatment plan.  PA determines the med dose should be increased.  Is there CMS documentation stating (clearly, if possible) that this visit may not be billed incident to?
2) Established patient with established treatment plan.  At the end of the visit the patient mentions a new problem.  The MD is called in to the room.  What must be done and documented by the MD?  Can the PA's exam and MDM regarding the established problem be considered in selecting the MD's EM level? 

 Would appreicate any input and official sources.  Thank you!


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## mitchellde

#1, if the PA changes the dosage then this is a new treatment plan and the PA is no longer following the treatment plan laid out by the physician, therefore you are no longer able to call this visit incident to and it must be billed under the PA number.
#2 This follows the Shared service definition (CR 1776) But the MD must document their part of the encounter with a reference to the PA note.  It must be more than "I agree with...".  It must be the MDs exam of the patient and subsequent treatment, it does not have to duplicate anything from the PA and it does not have to be lengthy but it must convey that the MD did in fact see and examine the patient.  And it must be a separate note.


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## sammie06

*Incident Too*

what are the rules/guidelines when the patient is not Medicare and is being seen by a NP. Does the physician have to be present in the suite. If they patient is there for a new conditions whom must they see. This is for the state of Missouri. Is there anywhere that the guidelines are posted for commercial and Medicare insurance.
Thank you so much.


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