Pain Management Coding Alert

Ask whether it’s chronic, acute, or recurrent.

Incident-to billing can boost your practice’s income, but only if you follow the rules. CMS guidelines include the directive that, “The physician should establish the care plan for the new patient to the practice or any established patient with a new medical condition. NPPs may implement the established plan of care.” Be sure you know what “new medical condition” means by brushing up on some billing basics. 

Area 1: Start With the Correct Foundation

The guideline above, from CMS, means that an NPP, such as a physician assistant or nurse practitioner, in your practice cannot see a patient with a new problem and bill incident-to under the physician’s national provider identifier (NPI) for 100 percent payment. Incident-to only applies when the NPP is seeing a patient for a problem the physician has already established a plan of care for.

Remember: If the NPP’s scope of practice and state laws allow, the NPP can see a patient for a new problem and bill under her own NPI for 85 percent reimbursement. 

For example, if a patient has low back pain and the physician sees the patient about the pain when it is new (first diagnosed) and establishes a plan of care, the patient can then see the NPP in follow-up and the office can bill the encounter incident-to the physician for 100 percent payment (assuming all other criteria for incident-to billing are met). However, if the NPP sees the patient for low back pain when it is new and the physician has never seen the patient for it and established a plan of care, it doesn’t meet incident-to requirements.

Payer differences: “One of the things we all need to keep in mind is that ‘incident to’ is a Medicare payment coverage benefit” says Jean Acevedo, LHRM, CPC, CHC, CENTC, president and senior consultant with Acevedo Consulting Incorporated in Delray Beach, Fla. “Not all payers honor the concept.”

Area 2: Verify ‘Condition’ vs. ‘Problem’

To get to the bottom of the issue, you need to ask another question: Is there a difference between a medical condition and a problem? 

“In the CMS incident-to guidelines, there is no distinction between a medical ‘condition’ and a ‘problem,’” Acevedo says. “If you think about what incident-to actually means, that the services are incidental to the physician’s services, it may make more sense as to what the circumstances must be to bill an NPP’s services under the name/NPI of a physician.”

Area 3: Define a ‘New’ Problem

The final piece of the puzzle is what actually qualifies as a new problem. Consider the following three categories to help you make that decision.

Chronic problems: For patients with chronic problems, you can bill incident to if the NPP is seeing the patient to follow through on the treatment plan and she is not making any changes to that plan. The physician must have already seen the patient for the chronic condition and set up the plan of care. 

Acute problems: For patients coming in with an acute problem, if the NPP sees the patient for that acute condition, the encounter doesn’t qualify for incident-to billing. “If the NPP sees the patient for the acute condition, by their very nature, treatment of these acute conditions are not incident to a physician’s service,” Acevedo explains.

Recurrent conditions: If providers in your practice are seeing a patient repeatedly for acute recurrent conditions, whether or not an NPP’s visit for the patient who comes in again with the same acute recurrent problem qualifies as incident to will depend on the particular circumstances. “It may meet the criteria if there is a formal standing order outlining the steps or changes in treatment the NPP is to follow based on defined criteria,” Acevedo says. “If, however, the NPP sees a patient for a recurrent condition and she switches the antibiotic to a different medication on her own, the services are not incident-to.”