Primary Care Coding Alert

Question: I’m coding a chart for an evaluation and management (E/M) visit in which a physician assistant (PA) performed the history and the exam, then the physician provided a provisional diagnosis and a care plan. The physician signed off on his part in this visit, and cosigned for the whole E/M. Should we bill this as an incident-to visit, or is this a regular visit billed to the physician?

Alabama Subscriber

Answer: Incident-to billing means that the service provided by a PA or other nonphysician provider (NPP) is being performed as a part of a care plan that a physician has already established. In order for this to occur, the patient must first be established with the physician; then the physician must personally evaluate the patient’s problem during the face-to-face part of the E/M visit. After this, the NPP must provide a service that helps execute the patient’s care plan in part or whole.

In other words, the NPP must be carrying out orders already given by the supervising physician. Any service an NPP carries out that cannot be tied to a patient care plan cannot be billed incident-to.

Given the scenario you describe, the E/M services provided by the PA were independent of a care plan, which the provider established later on the basis of the PA’s history and exam. As such, the service does not meet incident-to requirements.

Whether you can bill the visit to the physician as a regular visit may depend on the payer in question. For instance, the Medicare Claims Processing Manual, Chapter 12, section 30.6.1.B. says that “when an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed ‘incident to’ if the requirements for ‘incident to’ are met and the patient is an established patient. If ‘incident to’ requirements are not met for the shared/split E/M service, the service must be billed under the NPP’s UPIN/PIN, and payment will be made at the appropriate physician fee schedule payment.”

Other payers may simply allow you to bill the shared/split encounter as a regular visit under the physician’s provider number, so check with the payer in question if this is not a Medicare patient.