Meet the Incident-to Medical Billing Guidelines


Incident-to the physician’s professional service is an integral, although incidental part of the physician’s professional service and here’s the kicker. That professional, that nurse practitioner, that PA is following a plan of care established by the physician. This is the hardest thing to nail down but it's critical. So, when we’re auditing a non-physician practitioner visit, we don't just look at the visit we’re auditing today, we have to look back in the chart and find a documented plan of care that that non-physician practitioner is following.

Well, let's talk about auditing now. First of all, if it's an office service. Remember, you need the entire medical record, not just the state of service because if we're going to determine where the incident-to requirements met.

First of all, if it's an established patient, an established problem, then we're going to look to say, “Okay, was there previous visit to establish this plan to treat this problem?” So we'll look at that, it's not a new medical coding compliance problem, it looks like the non-physician practitioner is seeing him for an existing problem, we'll go back in the record and try to find that original visit that establish that plan of care.

Linking language would be great if the non-physician practitioner said following plan established by physician on whatever date. Also, it needs to be visited by that physician, addressing the problem. Does your carrier have specific frequency requirements? If they don’t, is that physician still seeing that patient often enough to really know what's going on with that patient?

One of the other provisions that we have not mentioned yet is that Medicare also says that it still could be considered an incident-to visit with any problem if it was such a minor problem that it didn’t affect the plan of care for the other issues going on. The whole picture is that CMS is if it's a minor problem such that wouldn’t affect the plan of care for the other problem, it still could be considered incident-to.

If you have met the incident-to requirements, you've got established patient, established problem, you're following the plan of care, but both the physician and the non-physician practitioner spent time counseling that patient, then this visit could be considered an incident-to visit and a shared visit and you would combine the time to support the level of service according to the medical billing rules.

If any of these requirements are not met, then you've not met the incident-to guidelines and the service must be billed under the non-physician practitioners on provider number.

If you've audited this and it has been billed as an incident-to service and maybe you determine, well, yes, the level of service met but it was not incident-to, it is incumbent upon you to re-bill that under the non-physician practitioner’s number and you'll end up refunding that 15% difference.

Well, if it's a hospital service, if it's an admission, it's a subsequent visit or a discharge as per the healthcare guidelines. We're going to look for some documentation. Is there a face to face visit by the physician on the same day? If so, then we're going to combine the documentation from the physician and the non-physician practitioner to support our level of service.

If it's a consultation, we can't combine that documentation. We have to bill under either the physician or the non-physician practitioner based on their individual documentation as per the evaluation and management documentation guidelines. Now, sometimes we might have a level four consult document by the non-physician practitioner and we would have a level one documented by the physician. And the level four, at 85% pays more than a level one at 100%. So you may need to look at that issue.

If you're physicians are determined to use their non-physician practitioners in consult, then you may have to look at billing those services under the non-physician practitioner’s name. And again, your carrier might have some specific issues with that.

Some of the carriers require a consult to be requested of the doctor of the providers who's going to do it. If it's a nursing facility service, that's easy. We throw all of these other stuff out and we just look at what the documentation is and we bill it under the non-physician practitioners on number.

Now, is there any limitation on the level of service billed by a non-physician practitioner? Officially, Medicare does not have any limit on the level of service billed. Some payers do. Blue Cross Blue Shield of Florida for example, they can only bill lower levels of service.

Our expert mentioned it in a billing conference that you must be aware that some consultants consider a higher level of medical decision making to be what it means to be a physician. So if you've got a visit that audit out to high complexity but it's done by non-physician practitioner, you may need to consider that idea that, you know, could that seriously be provided.

Get more coding updates and medical coding and billing information with our healthcare conferences page.