Wiki New Patient Visits

[OmegaPM]

I am a biller with a group in Tennessee, currently we have a system when a midlevel (NP) goes in and takes and documents the new pt encounter visit, goes out presents the case to the MD. He then goes in and finalizes the encounter and the plan w/ the new pt and we bill "incident-to" new pt visit under his NPI #. Is this correct even though she does 80-90% of the work? If we bill under her NPI we'll only get 65-85% of his reimbursement without "incident-to" billing. What is the right way to go about it without losing money?

 

[thomas7331]

The Medicare guidance on this is pretty clear that you cannot bill 'incident to' in an office setting for a new patient:

In the office/clinic setting when the physician performs the E/M service the service must be reported using the physician’s UPIN/PIN. 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.

 

[CodingKing]

What is the right way to go about it without losing money?

The only way to go about it without losing money is to not schedule new patient appointments with the NP. Though that will only help with new patients. You also cannot bill incident to if its a new problem on an established patient either. Trying to avoid having to bill under the NP could cost more than it saves. You would essentially be functioning as a one provider office vs a two provider office. Yes there will be lower reimbursement but the additional patients and lower expenses than a second MD, likely makes up for it.

 

[OmegaPM]

What if the MD gets help in seeing new patients from an experienced RN and not NP? A good RN with many years of clinical experience can probably contribute ~ 60-70% to the work required in seeing a new patient during an initial encounter. Any thoughts?

 

[thomas7331]

No, an RN is considered ancillary staff and their work and responsibilities are distinct and do not overlap with those of the physicians with regard to the components of an E&M service. Ancillary staff may collect the ROS and PFSH and vital signs and document them in the record, but the physician or NPP still must then review them with the patient and document that they have done so. Everything else must be performed and documented by the provider. (https://www.aapc.com/blog/27349-confirmed-billing-provider-must-document-the-hpi/)

An RN does not have the training or licensure to evaluate and diagnose a patient, even if they have many years of experience. They may only execute a provider's plan of care, not initiate their own. Diagnosing a patient and creating a plan of care is the principal work of an MD. The work an RN does is of value, to be sure, but for a physician to delegate "60-70%" of their own work to an RN would border on malpractice and could also be putting both the MD's and RN's licenses at risk.

 

[ellzeycoding]

"related" question posted by one of the MACs today (NGS Medicare)

>>Can an initial office visit be performed jointly by a physician and NPP and billed by the physician as a split/shared service?

Answer: An initial office visit requires three out of three components and all three components must be performed and documented by the billing provider. The billing provider may be either a physician or a NPP, but the concept of split/sharing an initial visit is not applicable. Split/shared visits in the office setting must be in compliance with incident to rules, so first visits are excluded. Subsequent office visits may be split/shared when both a physician and NPP participate actively in the visit and incident to guidelines are met. Subsequent visits may also be billed incident to when performed solely by an NPP and incident to guidelines are met. Added 4/17/2018 <<

https://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/policy-education/evaluation%20and%20management/em_split-shared%20and%20incident%20to%20services/!ut/p/a1/1VPbkqIwEP0VXuaRSoA44mNABx0vzM3S8GLFEDVTECiIzrpfv43O7lydS-2-bEgV1X06J92d0yhBc5RovlNrblShedbYyfmC0EHPcUI8jP0-xnTYpYROIi8iHpqhBCWjOEQsLLSWwiixNY3vflupOlWiIULs8pllDRtcr-tRHCB2xStjBX88b4mENqXZIAZwLoGCV1IU2khttHw4w8_cB7ssMiX2v_-WTLfiUIxlilKJ-gzLHc-2RxfXqZVzzdcyBzqA8kVdZsrY9Qbo0gOutFApoHDeqmW1U0LWTVoluBE77xC-7HQ8e8WlZxPhrmzfEcR2hUtaDhfwpccOPZU6Rwx6ik8sir_U8hchXuxjSi6Cbvf6yosC9zHggysY5NA-eUmI0e03a_yE0D0SzsLx4nrau4HoN0_NPlQMe6UX9p5a2CtF_bv8nf8sf9xyQBIhGbRJv-_Gd-2_fdBoOuhBQ4LhdDTF7iAi3ya8_EzXMBduNQ7Ha6DlZmMrvSrQ_OS4AvTVcZ1BN_c0ytoUlXnue4_bnuP7Vrn7eUcplUsfP1DazxeTic2X_v5Hi_4C2lDChg!!/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?LOB=Part%20B&LOC=Connecticut&ngsLOB=Part%20B&ngsLOC=Connecticut&jurisdiction=Jurisdiction%20K