Practice Management Alert

Question: We bill for a nurse practitioner who does initial consultations in our office only with a physician on premise. We bill for the visit under the supervising physician to all carriers including Medicare. She has reassigned her benefits to them. Is this correct?


South Carolina Subscriber

Answer: Unfortunately, your nurse practitioner cannot bill a consultation incident-to the physician (under the physician's number). One of the requirements for incident-to billing is that your physician established the patient's plan of care. But a physician has not established the plan of care when your nurse practitioner performs a consultation. The only way your nurse practitioner can bill a consultation is under his own provider number.

How it works: When a nonphysician practitioner (NPP), such as a nurse practitioner, performs a service incident-to a physician, the office can bill under the physician's Medicare number and secure 100 percent reimbursement.

But if the NPP does not provide services incident- to the physician, you must bill under the NPP's number -- meaning you receive 85 percent reimbursement for the same service instead of the full 100 percent.

Bottom line: If the physician has not established a plan of care, incident-to billing is impossible. The meaning of incident-to is that an established patient is following a prescribed course of treatment by the physician and is presenting for follow-up in the office, experts say.

Example: An NPP sees an established patient in the office to check on the patient's hypertension (99212, Office or other outpatient visit for the evaluation and management of an established patient ...). The physician is in the office supervising but does not see the patient.

In this instance, incident-to requirements were met -- this is an established patient with an established problem and plan of care, and the physician is in the office. Therefore, you may bill incident-to the physician using the physician's PIN for the NPP's service.