Pulmonology Coding Alert

Definition of new condition is crucial to distinguish incident-to services.

If your pulmonology practice, like many, is employing non-physician practitioners (NPPs) or mid-level providers (MLPs), such as physician assistants (PAs) or certified registered nurse practitioners (CRNPs) to increase the number of patients you can see while lessening the burden on your physicians, you know that billing for the NPP’s services can be tricky. If you’re not correctly identifying the patient’s problem as new or previously established, you could be mistakenly billing encounters incident-to the physician to those payers who follow Medicare guidelines.

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

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 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 for which the physician has already established a plan of care.

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

For example, if a patient visits your office with chronic bronchitis and the pulmonologist sees the patient about the condition when it is new (first diagnosed) and establishes a plan of care, the patient can then see the NPP in follow-up during any exacerbations or routine follow-up appointments, 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 bronchitis 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.

“Additionally, if the physician’s plan of care includes clinical protocols for any related issues the patient may experience (eg, increased dyspnea), then those too can be considered part of the treatment course and be billed incident-to when the physician is in the suite,” explains Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, director of PB Central Coding at Allegheny Health Network in Pittsburgh, Pa.

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, when a patient comes in for asthma medicine adjustment or for hemoptysis, 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 hemoptysis? What about when patients are seen repeatedly for asthma treatment? When are those considered new problems? 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 investigating any new causes of the problem. The physician must have already seen the patient for the chronic condition and set up the plan of care. “For example, a patient with chronic bronchitis comes in for routine evaluation and the NPP determines that he patient is stable on the current plan of care. This qualifies for incident-to services,” says Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania.

Acute problems: For patients coming in with an acute problem that cannot be traced to a previously established condition, 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. “These new and acute problems may require additional investigation to determine the cause,” Pohlig says. “For example, new hemoptysis may require the provider to order diagnostic testing to determine the cause, such as pneumonia, tuberculosis or an inflammatory process. Because the cause is under investigation, there is no established plan of care,” she explains.

Recurrent conditions: If providers in your practice are seeing a patient repeatedly for acute recurrent conditions, such as chronic obstructive bronchitis, 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. “If the patient comes into the office because he is having increased dyspnea even when using O2 at 2L via nasal cannula, the NPP may determine that the patient needs to increase the oxygen requirements. This is acceptable as an incident-to service because the clinical protocol for chronic obstructive bronchitis requires titration of home oxygen,” Pohlig adds.