Wiki Incident to for NP & PA's in Family Practice setting

[Cher91600]

I have read the incident to guidelines for billing NPP's under the MD's NPI for CMS, but I am wondering if there are any exceptions to this rule. These guidelines would suggest that most visits in a Primary Care setting would have to be billed under the NPP and paid at 85%; even with advanced oversight of the MD (reviewing & signing of on notes, agreeing to or adjusting treatment plans, and assisting with complex diagnostics). It just doesn't seem right that the NPP & MD collaborate provide thorough, timely services, but the office would only receive 85% of already low reimbursements for almost every visit that is scheduled (between new pts & pts who come in for f/u & present with new issues or need med changes) with an NP or PA. I feel like I must be missing something. Are there really no other billing options for billing NP & PA visits under the MD for full reimbursement except incident to or split billing?

 

[mitchellde]

sorry but no there are no exceptions. However if there is an adjustment of a treatment plan this cannot be incident to. Remember incident to means that the NPP is following an established plan of care. If there is an need to change anything or exam a new problem then this is where you cannot bill incident to and must bill under the NPP for the 85%. However IF the physician will see the patient face to face at the same visit and write his/her own note in addition to the note written by the NPP then you may bill a shared encounter which is you combine the complexity of both notes and bill one visit under the MD. But the provider must write an independent note not just sign off on the note provider by the NPP. You can see detailed info on shared encounters by looking up CR1776.

 

[Cher91600]

That's what I was afraid of....

Ugh, unfortunately it all makes sense. It just seems excessively punitive particularly to primary care providers. The purpose of a PCP is to have one place that the patient discusses their heart disease and their colds; their dementia and their allergies, etc. Patients almost never come in just to say their chronic condition continues to be well managed & head home. With reimbursement rates so low for PCP offices, I just don't know how anyone can afford to lose 15% on most of their NPP visits. I guess it was just wishful thinking that there might be something else out there.

Thank you for confirming I haven't missed something.