Ophthalmology and Optometry Coding Alert

Incident-To Coding:

5 Tips for Billing Incident-To Services

Published on Mon Jul 19, 2021

Hint: Don’t meet the requirements? Bill under the APP’s NPI.

When you’re reporting incident-to services, the medical record should include documentation noting that the physician is overseeing the provision of services appropriate for that patient’s condition.

That was one key insight discussed by NGS Medicare’s Carleen Parker during the Part B payer’s “Five Why’s for Incident To” webinar on March 12.

Background: The term “incident to” comes directly from CMS, Parker said. “Incident-to services are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness,” she noted.

To qualify for reimbursement, the service must be an integral part of the physician’s professional service, which is commonly furnished in the physician’s office. “The service is provided by a nonphysician practitioner or auxiliary personnel,” Parker said. “There must be direct physician supervision during the encounter.”

When billing this way, the practice collects 100 percent of the fee schedule amount because they’re reporting the service under the physician’s national provider identifier (NPI). If the services were billed under the NPI of the advanced practice provider (APP), Medicare would instead reimburse you at 85 percent of the fee schedule amount. Therefore, reporting incident-to services correctly allows you to retain the entire allowable amount.

Check out the following five tips for reporting your APP’s incident-to services accurately every time.

Tip 1: Make Sure the Physician Establishes the Plan of Care

To report services as incident to, the physician must perform the initial service for the patient to establish the plan of care and the diagnosis, and then the APP simply follows through on that plan of care at subsequent visits.

For example: The ophthalmologist sees a new Medicare patient with diabetic retinopathy, and schedules the patient for a follow-up visit. Two weeks later, the APP provides a level-three E/M service to check on the patient’s retinopathy.

In this instance, the NPP followed the doctor’s care plan, so you can report an incident-to service with 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter) for the E/M under the physician’s NPI.

One coder asked the NGS presenters what would happen if the physician established the plan for a patient, but the APP modified it during the visit. For instance, suppose a nurse practitioner changed medication dosages that the physician initially prescribed?

In this case, the physician’s initial plan of care would need to include latitude for a medication change as part of the initial program, said NGS’ Cathy Delli Carpini during the call. She noted that the documentation might include a recommendation for a particular medication at a certain dosage, “but it might say the medication can be decreased by 5 mg if it makes her drowsy or something like that — because then the plan of care is established and the nurse practitioner is just following it by changing the dosage by 5 mg,” Delli Carpini said. If the physician includes this type of statement, it can give the APP the latitude to make slight changes if necessary, but if not, then you cannot bill the service incident-to the physician.

Tip 2: Ensure That the Patient Is Established

To qualify for incident-to services, the APP must be seeing an established patient. “The concept of incident to does not apply to new patients, new problems, or new conditions,” Parker said. “Specifically, they must be established patients who have plans of care set up by the physician.

After the doctor performs the initial service, they should determine how often the patient must be seen to stick with the plan of care, Parker noted. The physician should see the patient at a frequency that reflects their active involvement in the patient’s care.

Tip 3: Direct Supervision Doesn’t Mean the Doctor Needs to Watch

Although the term “direct supervision” may make it sound as if the physician needs to be watching every minute that the APP is with the patient, that isn’t actually the case.

“CMS says that direct supervision in the office setting does not mean that the physician must be present in the same room,” Parker said. “However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time that the services are being performed.”

In some situations, you may have to ask yourself what makes a physician “immediately available,” Parker said. “Let’s say you have an office connected to a hospital, you’re paying fair market price in rent, and then that’s considered an office setting. However, if the doctor is doing hospital rounds while the nonphysician practitioner is seeing the patient within the office suite, the doctor is then not immediately available, and this wouldn’t qualify for incident-to billing.”

The physician can be in another room attending to a different patient, as long as they aren’t performing a procedure that cannot be stopped, Della Carpini added.

If the physician is a solo practitioner, they must personally be present in the office suite during the incident-to services, Parker said. “In a group practice, however, the physician who established the diagnosis and plan of care is not required to be the physician who is supervising the incident-to services,” she said. “It won’t necessarily be the original physician who is supervising the incident-to services.” That’s because any physician in the same group who is in the clinic or office suite and is immediately available to furnish assistance or direction if needed qualifies as the supervising physician.

Tip 4: Confirm That Your Documentation Meets the Requirements

When billing incident-to services, the documentation should include:

A clearly-stated reason for the visit
A means of relating the visit to the initial service and/or ongoing service provided by the physician
Information about the patient’s progress, response to, and changes/revisions in plan of care
The date the service was provided
The signature of the person providing the service

Know This Incident-To Terminology:

Get to know these terms if you’re aiming to perfect your incident-to coding:

Immediately Available: Means the provider is available “without delay” — in other words, the supervising physician is in the office suite or the patient’s home, readily available and without delay, to assist and take over care.
Office Suite: Limited to a dedicated area, or suite, designated by records of ownership, rent or other agreement with owner, in which the supervising physician or practitioner maintains a practice or provides services as part of multi-specialty clinic.

“While a co-signature of the supervising physician is not required, the documentation should contain evidence that they were actively involved in the care of the patient and were present and available during the visit,” Parker said. This could be accomplished by office schedules confirming that the physician was in the office suite, documentation of the plan of care that was created and signed, and any updates to that plan of care.

Tip 5: Keep State Scope-of-Practice Regulations in Mind

You must follow state scope-of-practice rules when determining who can report particular codes. For instance, a registered nurse (RN) can’t report an E/M code higher than 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal) even if they meet all of the other incident-to requirements, said NGS’ Nathan Kennedy during the call.

“An RN would report 99211 under the incident-to requirements, but a code higher than that cannot be billed to Medicare when performed by a registered nurse,” Kennedy said.

Consider This Checklist Before Billing Incident To

Services may be provided incident-to when:

They involve a face-to-face encounter
The physician has performed an initial service
The patient is established patient with an established diagnosis
The service is part of a continuing plan of care in which the physician will be an ongoing and active participant
The rendering provider is performing a service related to the service outlined in the plan of care
The supervising physician is physically present in the same office suite to provide supervision