Gastroenterology Coding Alert

Question: A new patient came in and the nurse practitioner (NP) took the initial history and performed the check-up. The physician was in and out of the room, and always available if needed. Is this visit billable as incident to?

Arizona Subscriber

Answer: No — new patient encounters are not covered under incident-to guidelines. This is because the physician must initiate treatment and see the patient regularly to show they’re actively involved in the ongoing treatment of the patient’s condition. This is not possible with a new patient because a treatment plan has not yet been established. Medicare’s incident-to guidelines assume that the physician will perform the initial visit on each new patient and establish that relationship.

Similarly, new problems are also not covered, even if the patient is established. That is because the new problem requires a new assessment, a new evaluation, and new management or treatment of the problem. The treating physician must first establish that the problem exists and then establish a treatment plan. You could possibly report subsequent visits with an NP as incident to, provided the nurse follows the treatment trajectory and the physician is available on the premises.