Practice Management Alert

Remember that not all payers follow the same rules.

While incident-to billing can boost your practice’s income, using non-physician practitioners (NPPs) can pose tricky billing situations if you aren’t clear on the rules. 

One reader posed a question to our experts about the key phrase “new medical condition” in the CMS incident-to billing guidelines. Read on to see our experts’ advice to ensure your practice is on the right track. 

Review the Question

Practice Management Alert reader, Sherry McCain, billing representative with Denver West Pediatrics in Colorado, wrote in to ask: “Our office is in desperate need of clarification on incident to. We need understanding for the following: ‘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.’ What does ‘new medical condition’ mean?”

Start with the Basics

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 hypertension and the physician sees the patient about the hypertension 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 hypertension 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.”

Examine “Condition’ vs. ‘Problem’

To get to the bottom of the reader’s question we must dig deeper. McCain continues, by asking: “Is there a difference between a medical condition and a problem? For example, a patient comes in for strep throat or an ear infection. Is this considered a problem/condition and can this be billed as incident to if the requirements are met?”

In the CMS incident-to guidelines, there is no distinction between a medical “condition” and a “problem,” Acevedo explains. “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.”

Define ‘New’ Problem

The final piece of the puzzle is what actually qualifies as a new problem. “Is there a distinction between chronic conditions such as asthma and acute conditions like ear infections? What about when patients are seen repeatedly for ear infections or strep throat? When are those considered a new problem? Or are they?” asks McCain. 

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,  such as otitis media, 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, say,

 for the third ear infection and she switches the antibiotic to a different spectrum on her own, the services are not incident to.”