Wiki Billing for Nurse Practioners Incident-To - new dx is determined

[lillianivy]

We have Nurse Practioners (NP)who see pts as follow-up care and work-ins. We are trying to determine the fine lines of incident-to. A Physician is always in the office when a pt is seen by a NP.

Scenario 1:
Pt comes to clinic for follow-up care with no new complaints. During the visit the NP reviews the labs and a new dx is determined per the labs and a new drug/treatment plan is given. IE.. pt now with chemo induced anemia and Procrit is ordered. So the initial plan of care as been altered and the physician did not have a face-to-face encounter with the pt and the physician did not sign the record nor made an entry, is this visit no longer an incident-to visit and can now be billed under the NP?

Scenario 2:
Pt comes in for new symptom of weakness, and N/V due to chemo(work-in). Pt only sees NP and fluids are ordered and Zofran prescription given. Physician does not have a face-to-face with pt and did not sign record. Is this not an incident to and can be billed under the NP?

Scenario 3:
Same as scenario 2 but physician does have a face-to-face and makes an entry in the record and signs record. Bill under physician? Does Physician need do all 3:
1. Have a face-to-face
2. Make an entry in record
3. Signs record
Or can the NP make an entry stating(Then sign record alone):
"Dr. Smith saw pt with me and created Plan of care."

Scenario 4:
Pt has follow-up with NP. No new complaints. No change in plan. Prescriptions refilled. Continuous labs ordered and follow-up radiology test ordered. Is this considered incident-to? Physician is in office but did not have a face-to-face encounter with the pt and the physician did not sign the record nor made an entry. Therefore, bill under physician.

Scenario 5:
Pt has follow-up with NP after Initial visit with the physician where treatment plan was created. NP does a Chemo teaching visit. Is this considered incident-to? Physician is in office but did not have a face-to-face encounter with the pt and the physician did not sign the record nor made an entry. Therefore, bill under physician?

Scenario 6:
How NPs are educated in Genetic Counseling and Survivorship Counseling. They see pts in addition to treatment, ect. The physician does order it in last visit, but during this encounter the pt only sees the NP. Therefore, bill under NP?

Please Help!! Need clarification.

Thank you,
Lydia

 

[RhondaCPC]

Hi,
Are you billing for facility outpatient visits? If so, incident-to rules do not apply.

 

[thomas7331]

Agree with the above, if the visits are rendered in a facility, all services need to be billed under the NP unless meeting the qualifications of a shared visit (e.g. scenario 3 if both NP and MD perform and document portions of the E&M service).

If in the office, you're correct, scenarios 1 & 2 are not incident to because of the new problems and cannot be billed under the MD since he/she did not see the patient. Scenario 4 could be billed as incident to since there is no new problem and no change to the care plan.

Scenarios 5 & 6, hard to say without reviewing the documentation, it does sound like the incident to requirements are met but for teaching and/or counseling, it may or may not be billable depending on whether it qualifies as an E&M visit and whether or not it is inclusive in other services performed on the same date.