Primary Care Coding Alert

Question: One of our non-physician practitioners saw a patient during a follow-up visit. What requirements must we meet to report these services to Medicare as incident to the physician?

Florida Subscriber

Answer: To qualify as an "incident to" visit, the physician must have seen the Medicare patient during a prior visit for the same problem and established a clear plan of care, to which the follow-up visit provided by the non-physician practitioner (NPP) is related. If the NPP is treating a new problem for the patient, or if the FP has not established a care plan for the patient, then you cannot report the visit incident to.

Remember: When meeting the requirements for a follow up to an established plan of care, if the physician does not directly supervise the NPP, the incident-to rules do not apply. Direct supervision means a supervising physician must be immediately available in the office suite. The supervising physician, however, does not necessarily need to be the same physician who established the patient's care plan.

Example: An established Medicare patient reports to the FP on May 10. The doctor performs an E/M service, diagnoses the patient with atopic dermatitis (691.8), writes prescriptions, and asks the patient to return in one week to follow up with the nurse practitioner. On May 17, the patient returns to the office for a follow-up visit. The NP evaluates the patient's dermatitis and performs an examination. The NP recommends continuing with the prescribed medication and returning for follow up in one month.

In this example, you can report the NP's service incident to the physician, as long as the supervising physician was immediately available in the office suite when the nurse practitioner saw the patient on May 17. On the claim, report the appropriate level E/M code. Don't forget to file the claim under the supervising physician's national provider identifier (NPI) rather than the NP's NPI; this ensures you 100 percent pay for the E/M, while coding under the NP's NPI results in 85 percent pay for the service.

Best bet: Check your Medicare contractor's guidelines for NPP qualifications and credentials for billing incident-to. If the NPP does not meet those guidelines, don't bill incident-to for her services.

Warning: Do not assume that private payers and your state's Medicaid follow Medicare's incident-to rules. For example, Kansas Medicaid does not recognize incident-to billing.