Wiki Incident-to questions

[Coder2468]

I'm hoping someone can help me out here. I'm pretty familiar with the criteria that must be met in order to bill NPP services as incident-to. I've explained them to my physician, and he came up with what he feels are appropriate scenarios for incident-to. I disagree and am looking for documentation to back myself up.

I know that incident-to requires that the NPP cannot change the patient's plan of care for an established diagnosis. The physician feels that by putting "Patient may follow up with NPP, and NPP may adjust plan of care as related to diagnosis" in the notes, the NPP can change the plan of care and have it still be incident-to - because now the plan of care states that the NPP can make decisions. I disagree with this, but can't find anything in writing to back me up.

Other scenario - physician feels that if the NPP sees the patient but documents it under the physician's name, and then physician signs the notes, then we can bill as incident-to. I, again, disagree. I feel the documentation needs to be done under the NPP's name, and then if the criteria is met, bill incident-to.

Can anyone direct me to links that cover these scenarios? I have tons of info on general incident-to rules, but they don't get specific like this. Thanks!

 

[thomas7331]

Regarding your first scenario, I'd direct you to the guidance in the Medicare Benefit Policy Manual, Chapter 15, section 60: "there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the nonphysician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment. In addition, the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary."

Obviously this guidance is a bit vague and would involve some medical judgment as to where to draw the line between an 'incident to' and a service that is initiated by the NPP. But I don't think that this is meant to imply that the NPP cannot 'make decisions'. NPPs routinely make adjustments, within reason and guidelines, to a physician's plan of care, such as changes to a dosage of medication and this can still qualify as an 'incident to' service. It would not make sense to not to have the patient see an NPP if they did not have any discretion at all. Since this is a matter of medical practice and outside the scope of coding, I would leave it up to the physician to determine where this distinction should be made. But I would point out the regulation above which does require the physician's continued participation in the patient's management - they can't simply turn the patient over to the NPP for open ended continued care for that diagnosis indefinitely.

In the second scenario, it would not be compliant for one provider to document under another provider's name - this would be falsification of the medical records. Documentation must be authenticated by each provider. I can't imagine that a physician would knowingly allow an NPP to document under their name because if a medical error or malpractice issue were to occur, the physician could be liable and their license at risk. In addition, if using an EHR, the credentials of each provider must be secure and not shared as the audit trail must show who made what entries so that integrity of the medical record is not compromised. If you need official guidance about this, here's a good link as a starting point:
https://www.cms.gov/Outreach-and-Ed...gnature_Requirements_Fact_Sheet_ICN905364.pdf

 

[Coder2468]

Thank you so much for your response. Regarding scenario 1 - I have been under the impression that NPPs cannot do things like adjust medications in order to be incident-to. I have some information printed on this, but can't link it right now because I'll have to go dig it out and find where I printed it from. I agree that it would be pointless to have an NPP see a patient if they can't do anything. I'm worried the doctor is using the "NPP can adjust plan of care..." phrasing as a way to skirt around incident-to rules. His logic is truly that "the plan of care is now turned over to the NPP and the NPP can do whatever is needed for this diagnosis, and it's incident-to."

The second scenario seems like a no-brainer to me, I just can't find anything in writing to help me out. I'm starting with your link. I really appreciate you taking the time to help!

 

[thomas7331]

I agree with you, a blanket statement of "NPP can adjust plan of care..." does not exempt the provider from the requirement that the documentation must reflect the provider's continuing participation in the management of the patient's condition. Probably a prudent approach would be to have the physician review and sign off on any adjustments to the plan of care made by the NPP to reflect their involvement in it. But I don't believe there's a requirement for the physician to see the patient personally any time a change is made in order to bill 'incident to'. Perhaps someone who's had experience with payer audits of these types of claims might be able to give some more input.

 

[jimbo1231]

Incident To after Physician Phone Call

I have a question about "direct physician contact". One of out providers asked whether "incident to" can be billed by PA after the physician has a call with the patient establishing plan of care. I thought that was questionable and might not meet the contact requirement. Also it raises a billing question since there is no New Service billed, and NP incident to must be Established. But doc did establish POC and is in office supervising for the NP visit.

Jim S.