Medicare Compliance & Reimbursement

Even the most seasoned coders find incident-to coding confusing and troublesome. And that’s why it is critical to understand the various nuances about how to code incident-to services because one misstep can get you into hot water.

Tip 3: New Visits, New Problems Aren’t Covered Under Incident-to

Although incident-to covers a wide range of services in the office, one thing it doesn’t cover is a new patient visit or a visit to address a new problem, Obergfell said.

“An initial history and physical performed by a nonphysician practitioner, although the physician is documented as being present or in the office suite and immediately available, is not covered under the incident-to guidelines,” she said.

That’s because under Medicare’s incident-to guidelines, the physician must perform the initial service and establish a plan of care. “This includes the history and physical examination portion of the service and the treatment plan,” she said. “It is expected that the physician will perform the initial visit on each new patient to establish the physician-patient relationship,” if the NPP will be billing incident-to.

When billing incident-to, the physician must initiate treatment and see the patient at a frequency that reflects their active involvement in the patient’s case, Obergfell said. “This includes both new patients and established patients being seen for new problems.”

Consider this example: A physician sees a patient for elevated blood pressure and GERD and wants the patient seen every three months. The patient returns at three-month intervals and is seen by the nurse practitioner (NP) for these distinct problems under the physician’s plan of care. The NP’s services are billed by the supervising physician under the incident-to guidelines.

If the established patient who returned in three months now has a complaint of rectal pain in addition to the management of their GERD and elevated blood pressure, they could not be seen incident-to by the NP since there is a new problem. But since they are scheduled with the NP, they could be seen by the NP and the service can be billed under the NP’s NPI, for which Medicare will allow 85 percent of the physician fee schedule amount.

Tip 4: Know What ‘Integral’ and ‘Incidental’ Mean

In order to be covered as an incident-to the physician service, the NPP’s service must be an integral, although incidental, part of the physician’s professional service, Obergfell said. “Now, ‘integral/incidental’ just means the physician must perform the initial service to establish the diagnosis, and the follow-up services rendered must be connected to the course of treatment that the physician planned at the initial service. ‘Integral’ is related to a previous service and is tied to that previous service. It must be a service commonly furnished in a physician’s office or clinic and must be furnished by the physician or by auxiliary personnel under the physician’s direct supervision.”

Tip 5: The Doctor Should Maintain Direct Supervision

To qualify as an incident-to service, there must be direct physician supervision of the NPP providing the service, Obergfell maintained. “Direct supervision means the physician must be present in the office suite and immediately available and able to provide assistance and direction throughout the time the service is performed. It does not mean that the physician must be present in the room where the procedure is performed.”

Tip 6: Physician Must Be Immediately Available

To qualify for incident-to services, the supervising physician must be immediately available, Obergfell explained. “CMS has clarified that ‘immediately available’ means ‘without delay,’” she said. In an office suite, it is limited to the dedicated area or suite designated by records of ownership, rents, or other agreements with the owner, she noted.

Some people have questions about where the physician can be if their office is located near a facility. “If your office is connected to a hospital and you are paying fair market price for rent, then it is considered place of service ‘office,’” Obergfell said. “That doesn’t mean you can be doing hospital rounds while your NPs are seeing patients within your office suite.”

However, the physician can be in another room attending to a different patient, she noted. “As long as they are not performing a procedure that they cannot stop and go to help with the other patient,” then they are considered immediately available, she related.

Tip 7: In Group Practices, Other Physicians Can Provide Direct Supervision

If a physician is a solo practitioner, then that doctor must be present in the office to qualify for direct supervision. If, however, you are in a group practice, the physician who established the diagnosis and plan of care is not required to be the physician that is supervising the service, Obergfell explained.

“Any physician member of that group may be present in the office to supervise,” she noted. “So that supervising physician in a group practice is not necessarily the physician who performed the initial patient visit, not necessarily the patient’s primary care physician, and not necessarily of the same specialty as the primary physician. Any physician in the same group who was in the clinic or office suite and is immediately available to furnish assistance or direction if needed, can be that supervising physician for incident-to services.” Make sure that the NPI that the incident-to service is billed under is NPI for the physician who is physically present in the office, providing the direct supervision, even if that physician is not the treating physician who developed the patient’s plan of care. Never bill out -incident-to services under a physician’s NPI for a physician who is not present in the office even though another doctor is present.

Tip 8: Check State Guidelines

“The personnel that provide incident-to services must have sufficient training to provide the services, and when appropriate, they must be licensed under state law to perform without physician supervision,” Obergfell noted.

Tip 9: Make Sure Documentation Establishes the Plan of Care

To qualify as incident-to services, the NPP should be following the plan of care that the physician set, and any reviewer should be able to find that plan of care in the documentation. “Medical records should include sufficient documentation indicating that the physician is overseeing the provision of services appropriate for that patient’s condition,” Obergfell said.

Tip 10: Make Sure the Medical Record Includes a Signature

Documentation for incident-to visits should include a clearly stated reason for the visit, a means of relating this visit to the initial service, and/or demonstration of ongoing service provided by that physician, Obergfell said.

The patient’s progress notes relating to the plan of care, the date the service was provided, and the signature of the person providing the service should all be present in the record, she noted.

“While co-signature of the supervising physician is not required, documentation should contain evidence that he or she was actively involved in the care of the patient and was present and available during the visit,” Obergfell stressed. “This could be accomplished by office schedules that indicate the supervising physician was present in the office suite and documentation of the patient’s plan of care that was created and signed, or any updates to that plan of care.” A best practice for incident-to providers’ documentation is to start their documentation with a statement such as, “Dr. Smith is present in the office today providing direct supervision.” That way, on audit, Medicare can easily reconcile the charges against Dr. Smith’s NPI to these documented statements showing that Dr. Smith was present.