Wiki Incident-To Billing - new symptom/condition ???

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eharloff

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Can someone tell me whether or not an acute illness, like sinus infection, ear infection, etc., is considered a "new problem" and if an APP/NP can diagnose/treat patient if billing incident to. I just feel like something so simple shouldn't be considered "new condition" that the MD/DO hasn't seen pt initially for treatment since it's not a chronic concern, but I also cannot for the life of me find this answer anywhere.
 
eharloff said:
Can someone tell me whether or not an acute illness, like sinus infection, ear infection, etc., is considered a "new problem" and if an APP/NP can diagnose/treat patient if billing incident to. I just feel like something so simple shouldn't be considered "new condition" that the MD/DO hasn't seen pt initially for treatment since it's not a chronic concern, but I also cannot for the life of me find this answer anywhere.
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That would not be an incident-to service and should be billed under the APP/NP's NPP.

Here's an example from the Indiana State Medical Association. (I know you're in Michigan, but ISMA's references at the bottom of this handout have links to WPS resources that were used in creating this document.)


1733763995717.png
 
If your provider does not have an NPI in order to bill Medicare, they should not be seeing patients until that credentialing is in place. Commercial payers will often allow midlevels that are unable to be credentialed to bill under a supervising provider, but that's different than the Medicare incident-to rules.
 
Pam Warren said:
If your provider does not have an NPI in order to bill Medicare, they should not be seeing patients until that credentialing is in place. Commercial payers will often allow midlevels that are unable to be credentialed to bill under a supervising provider, but that's different than the Medicare incident-to rules.
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If I had to guess, she's probably talking about a specific Michigan insurer that doesn't credential Nurse Practitioners.

My employer has one small office in Michigan, and I know that payer causes many issues for our schedulers. Fortunately we only have that one small office in Southeast Michigan, so we don't have a ton of business from them.

Since OP is in West Michigan and the payer is a key player on that side of the state, I can only imagine how much bigger their headaches are from that payer!
 
eharloff said:
So my next question is...what if the specific payer doesn't allow direct billing?
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You would be talking about something different than incident to in that case. There are some payers/states/possibly MCD (as suggested above) where the services have to be billed under the MD. It's not incident-to in that case.
You have to check the agreement for the payer, your contract and state law. This really tripped me up once in the past because I was dealing with claims where the claims were filed under the MD but a PA or NP was rendering the service. It did not meet incident to but the random/specific payer dictated it had to be billed that way. They did not credential/recognize the mid-levels or APPs and also did not have the concept of incident to. I had never seen it before and was used to the Medicare way and incident-to.
 
Pam Warren said:
If your provider does not have an NPI in order to bill Medicare, they should not be seeing patients until that credentialing is in place. Commercial payers will often allow midlevels that are unable to be credentialed to bill under a supervising provider, but that's different than the Medicare incident-to rules.
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It's not Medicare. She's credentialed with Medicare. It's actually Cigna that I'm having an issue with this. But also, I just received a Medicare denial stating " Missing/incomplete/invalid billing provider/supplier contact information" but she's credentialed with Medicare so I'm not sure why that's denying either.
 
amyjph said:
You would be talking about something different than incident to in that case. There are some payers/states/possibly MCD (as suggested above) where the services have to be billed under the MD. It's not incident-to in that case.
You have to check the agreement for the payer, your contract and state law. This really tripped me up once in the past because I was dealing with claims where the claims were filed under the MD but a PA or NP was rendering the service. It did not meet incident to but the random/specific payer dictated it had to be billed that way. They did not credential/recognize the mid-levels or APPs and also did not have the concept of incident to. I had never seen it before and was used to the Medicare way and incident-to.
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I'll have to get all that information! Thank you so much :)
 
sls314 said:
If I had to guess, she's probably talking about a specific Michigan insurer that doesn't credential Nurse Practitioners.

My employer has one small office in Michigan, and I know that payer causes many issues for our schedulers. Fortunately we only have that one small office in Southeast Michigan, so we don't have a ton of business from them.

Since OP is in West Michigan and the payer is a key player on that side of the state, I can only imagine how much bigger their headaches are from that payer!
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It's actually Cigna that I'm dealing with currently. I haven't had any issues with our smaller insurance companies. Honestly, this whole thing is a nightmare. lol
 
eharloff said:
It's not Medicare. She's credentialed with Medicare. It's actually Cigna that I'm having an issue with this. But also, I just received a Medicare denial stating " Missing/incomplete/invalid billing provider/supplier contact information" but she's credentialed with Medicare so I'm not sure why that's denying either.
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"Incident-to" is a Medicare thing. Unless your commercial payers strictly follow CMS guidance, generally you bill under a supervising MD if the state Nurse Practice Act doesn't mandate midlevels being able to bill under their own names. As I think you're finding....commercial payers are many, and they all have their own random rules.
 
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