Ob-Gyn Coding Alert

Question: A gyn patient was seen by a nurse practitioner for an established vaginitis problem. The NP identified a new problem of condylomatous lesions, and they were removed. If billing Incident To wouldn’t a physician need to present an establish treatment of care in order for this to be billable?

We have some additional questions. Our NPs are questioning if a new patient presents for vaginitis, UTI, STDs, are these considered new problems that need to be addressed does a physician need to present an establish treatment of care in order for this to be billable? Also, would a physician need to present first for birth control options such as IUD, oral contraceptive counseling? If a patient presents and has only seen NP, never seen physician and presents with an old problem is this incident to or not billable?

Texas Subscriber

Answer: For your first question, the answer is yes — so long as this was a Medicare patient or the payer follows this Medicare rule. Incident-to rules were established for Medicare billing purposes and are not followed by all payers. Also, in your first question you are indicating the NP removed the lesions – this would never be considered an incident-to service since the billing/supervising provider would have to have established this as the treatment plan, and a surgical procedure (rather than E/M service) was provided.

As for your other questions, the rules vary by payer. Medicare has specific rules for reporting services provided by an NPP, but private insurers can set their own standards. Likewise, state Medicaid programs and managed Medicare and managed Medicaid plans may set their own rules. For Medicare, the provider whose number you are billing under must be present to bill. Medicare also requires that the incident-to service be part of an established plan of care, which means the billing provider would have to have seen the patient first. This is always the case with a new patient.