Wiki Incident-to ???

[jennifernelson20]

Couple of questions.......1--does the physician need to be in the clinic at time of visit?....2--is there a modifier required for this? i found "SA", but it seemed like outdated info? I'm a very new coder and still figuring things out. In my clinic the APRN sees the pt and lists our "physician was available for consultation during this visit" in the note. i do not normally add a modifier of any kind and then it is billed out under the APRN name/TIN. I guess my other question is am i even billing incident-to since it is being billed under the APRN name/TIN? Thanks!

 

[s.johnson]

If your billing under the APRN then no it would not be incidental to. Incidental to would be if the patient saw the APRN, but you are wanting to file the claim under the physician. If you were to do incidental to a physician would need to be in the office at the time of the visit.

 

[CBLENNIE]

In response to question #1, yes a physician (MD, DO), which can be any physician in the medical group, must be onsite at the same clinic as the APRN, although they do not need to see the patient and it is not required that the physician onsite be the same physician who initiated the patient’s plan of care. As for question #2, while modifier SA exists it is rarely used with commercial insurance and I don’t believe it is required for Medicare or MA plans, I have a feeling it is mostly used by Medicaid plans. As @s.johnson stated the scenario you outlined is not considered an incident to service and it is appropriate to bill the service under the APRN.

Here is a brief description of what an incident-to visit would require. The physician (MD or DO) must see the patient first and establish the plan of care, then the APRN can take over subsequent visits as long as they follow the physicians original plan of care. If they change the physicians plan of care the physician must be involved in the change, which would still constitute an incident-to service by the APRN. However, if the APRN does not involve the physician in the change to the physician's plan of care the service is no longer an incident-to service and would be billed under the APRN. Obviously, a new patient visit with the APRN cannot be an incident-to service since the physician will not have established a plan of care for the new patient. Also, incident-to services are not applicable to services rendered in an institutional setting.

Here is a great AAPC blog article regarding incident-to billing 7 Incident-to Billing Requirements.

Lastly, technically incident-to billing is a Medicare or MA plan rule, although many commercial insurance companies follow it, not all of them do, so you may need to research the various commercial insurance companies you file claims with to find out if they apply the incident-to guidelines in accordance with Medicare's guidelines or not.