Wiki Incident To- true or false?

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The NPP is able to perform visits for New Patients as long as the physician reviews and signs the document, and the NPP signs the document.
True or False?

If the NPP performs Initial Visit and Dr. Signs off on the document, 3 of 3 requirements were met between the Dr. and the NPP work performed, the service is billed to Dr. or PA?

Thanks!
 
Here is Medicare/CMS definition of incident to services:

“Incident-to services are defined as those services that are furnished incident-to physician professional services in the physician’s office or in a patient’s home. . These services are paid at 100 percent of the physician fee schedule, while services reported by Non-Physician Practitioners are paid at 85 percent.”

To Bill Incident To:

  1. The services must be rendered under the direct supervision of the physician (meaning the provider is in the office)
  2. The services are furnished as an integral part of the physician's plan of care for a specific diagnosis or injury
  3. The physician must initiate treatment and define a plan of care and see the patient at a frequency that reflects his/her active involvement in the patient's case.
  4. If the NPP is seeing the patient for services not related to the plan of care set up by the provider (another dx, etc) then the service would not be incident to and would be billed under the NPP NPI and reduced at 15% for payment.

So if I understand your questions below, you have NPP who is seeing a patient for a visit where no plan of care is in place (new visit or issue). In this case incident to does not apply. The service can be billed under the NPP with the physician but may be reduced based on your payer.
 
for incident -to requirements
the patient must be established with the MD for the same dx the NP is seeing the patient
The MD must have a written plan of care in the initial visit that includes the patient will be followed up with the NP
the MD must be present in the office suite area at the time of the encounter
What cannot be incident - to
New patient
established patient with new diagnosis
established patient with the established diagnosis but the NP changes the treatment plan
Any visit where the MD you are billing under is not in the office suite at the time of the encountet.
 
Thank you all, it's making more sense, and I completely understand the 'concept' of incident to. We are a speciality practice (radiation oncology), and on the initial visit, the Dr. will typically recommend and INITIATE a 'POC' for the disease/cancer. Which meets the incident to guideline.........

HOWEVER, the physician doesn't meet the 3 of 3 requirement, with NO EXAM. The dictation is Shared. the PA does their work and signs, the Dr. does their work and signs. 3 of 3 criteria are met with the COMBINED work of the Dr and staff.



So if I understand your questions below, you have NPP who is seeing a patient for a visit where no plan of care is in place (new visit or issue). In this case incident to does not apply. The service can be billed under the NPP with the physician but may be reduced based on your payer.
What ..If the plan of care IS initialed, but the Physican does not do an EXAM or meet his/her portion of the 3 of 3, is it still billable as incident to, b/c the PA did the exam??
 
Our typical scenerio for rad onc initial office visit:

NEW Patient SHARED visit with PA: Physician did initiated POC and did no exam, be billed to the PA?
Who is required to meet the 3 of 3, b/c the PA did not meet 3 of 3, and the Dr. didn’t meet 3 of 3. Based on who performed their portion of work.

Thanks, sorry for going round and round.
 
guamafb@gmail.com said:
Our typical scenerio for rad onc initial office visit:

NEW Patient SHARED visit with PA: Physician did initiated POC and did no exam, be billed to the PA?
Who is required to meet the 3 of 3, b/c the PA did not meet 3 of 3, and the Dr. didn’t meet 3 of 3. Based on who performed their portion of work.

Thanks, sorry for going round and round.
Click to expand...

In the office setting, new patient visits may never be billed under the physician if it is a split/shared service - in order to meet the requirements to be 'incident to' in a shared visit scenario, the patient must be established - see below from the Medicare Claim Processing Manual. In this situation, you would have to bill the entire shared visit under the NPP.

When an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed “incident to” if the requirements for “incident to” are met and the patient is an established patient. If “incident to” requirements are not met for the shared/split E/M service, the service must be billed under the NPP’s UPIN/PIN, and payment will be made at the appropriate physician fee schedule payment.
 
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Thank you Thomas,

When billing a new patient visit using the NPP NPI # due to split/share office visit not meeting incident to requirements, we can screen the EM service as one entire document to include the work of both the physician and NPP correct?

What if the Dr. does NOT perform an exam on the Initial consultation, but does provide a POC and initial treatment (rules for establishing incident to). Can we bill a subsequent visit as incident to the physician since he established a plan of care, even though no exam by the Dr. was performed that we know of?

We were told, that we were not allowed to bill any subsequent visits incident to the physician if the physican never performed an exam (proof of signature under examination performed) I feel like this is overstating the guidelines, and preventing us from billing incident to, if the physician established a plan of care.

Thanks!
 
guamafb@gmail.com said:
When billing a new patient visit using the NPP NPI # due to split/share office visit not meeting incident to requirements, we can screen the EM service as one entire document to include the work of both the physician and NPP correct?

What if the Dr. does NOT perform an exam on the Initial consultation, but does provide a POC and initial treatment (rules for establishing incident to). Can we bill a subsequent visit as incident to the physician since he established a plan of care, even though no exam by the Dr. was performed that we know of?

We were told, that we were not allowed to bill any subsequent visits incident to the physician if the physican never performed an exam (proof of signature under examination performed) I feel like this is overstating the guidelines, and preventing us from billing incident to, if the physician established a plan of care.
Click to expand...

Neither of these questions, to my knowledge, is addressed directly in CMS regulations regarding 'incident to' billing, so these are decisions your practice will need to make and I can only offer my opinion.

To your first question - I would agree with you that you should bill the EM service under the NPI credentials as a single service representing the work of both providers. As both providers are employed in the same practice, the payment is going to the same entity. The work of the MD is not disqualified from payment simply because you are combining the two services, and since you are billing under the lower-paid credentials, you are not at risk of causing an overpayment as you would be by billing under the physician.

To the second question - if you read the 'incident to' regulations on this topic (see Chapter 15, Section 60 of the Medicare Benefit Policy Manual), they only state that the services must be "an integral, although incidental, part of the physician’s professional service...Commonly rendered without charge or included in the physician’s bill...Of a type that are commonly furnished in physician’s offices or clinics...Furnished by the physician or by auxiliary personnel under the physician’s direct supervision". They further explain that "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." Naturally, there is some room for interpretation here as to exactly what is required in order for a physician to initiate and supervise a course of treatment, and most standards of care would likely say that a physician would routinely perform some kind of exam of a new patient as part of creating a plan of care. But be that as it may, there is no explicit mention here of a requirement that the documentation of this initial service by the physician must include an exam. I'm not sure what is the rationale behind your being told that an exam must have been performed, so I would direct that question to the person who told you this - they may be aware of guidance that I am not, or they may simply be making their own interpretation of these guidelines, setting internal standards for document quality and/or acting out of an abundance of caution to protect against audit risk.

Hope this helps some.
 
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