Pediatric Coding Alert

Hint: Texas Medicaid recently changed its incident to rules.

A new condition to you may not be new to the patient— so does incident to billing apply? This is one tricky question that may be on your mind –but you can check out the solution to this dilemma about using non-physician practitioners (NPPs) in your practice.

One reader posed a question about the key phrase “new medical condition” in the incident-to billing guidelines. The guidelines state, “The physician should establish the care plan for the new patient to the practice or any established patient with a new medical condition. NPPs may implement the established plan of care.” But what does “new medical condition” mean?

Start with the Basics

The guideline above means that an NPP, such as a physician assistant or nurse practitioner, in your practice cannot see a patient with a new problem and bill incident to under the physician’s national provider identifier (NPI) for 100 percent payment. Incident to only applies when the NPP is seeing a patient for a problem the physician has already established a plan of care for.

Remember: If the NPP’s scope of practice and state laws allow, the NPP can see a patient for a new problem and bill under her own NPI for 85 percent reimbursement.

For example, if a patient has diabetes and the pediatrician sees the patient about the diabetes when it is new (first diagnosed) and establishes a plan of care, the patient can then see the NPP in follow-up and the office can bill the encounter incident to the physician for 100 percent payment (assuming all other criteria for incident to billing are met). However, if the NPP sees the patient for diabetes when it is new and the pediatrician has never seen the patient for it and established a plan of care, it doesn’t meet incident-to requirements.

Some Medicaid Payers Have Their Own Rules

Although we might think of incident to rules as being enforced universally among payers, the reality is that not every insurer honors incident to, and various state Medicaid program handle incident to differently from one another.

Example: Texas Medicaid recently spelled out its incident to guidelines, which appear to be more stringent than the standard rules.

“Previously, Texas Medicaid was silent about physician supervision and involvement in care for services billed incident to, which presented practices with both flexibility and uncertainty,” says Kris Kwolek, JD, partner with Husch Blackwell LLP in Texas.

This changed significantly effective Jan. 1, when the state specified how the physician must be involved in the patient’s care to qualify for incident to billing. “The physician must make a decision regarding the patient’s care on the same date as the service rendered by an APRN or PA and the physician’s involvement and decision must be documented in the record,” Kwolek tells The Coding Institute.

If your state Medicaid program has a regulation similar to this, making it stricter than the standard guidelines, be sure that your documentation stands up to the requirements.

Best bet: “I think to best mitigate risk under the new requirements, a billing physician should at least counter-sign the record of service provided by the PA or APRN on each date of such service,” Kwolek advises. “A countersignature arguably establishes that the counter-signing physician decided care and treatment documented in the record was appropriate. Any additional specific details a physician adds – such as care instruction or changes advised by the physician – would further support compliance. It is important that the record of physician decision-making be dated to mitigate against recoupment based on an inability to show when the decision-making took place.”

Examine “Condition’ vs. ‘Problem’

To get to the bottom of the “new problem” question, we must dig deeper and evaluate whether a difference exists between a medical condition and a problem. For example, a patient comes in for strep throat or an ear infection. Is this considered a problem/condition and can this be billed as incident to if the requirements are met?

In the standard incident-to guidelines, there is no distinction between a medical “condition” and a “problem.” If you think about what ‘incident to’ actually means, that the services are incidental to the physician’s services, it may make more sense as to what the circumstances must be to bill an NPP’s services under the name/NPI of a physician.

Define ‘New’ Problem

The final piece of the puzzle is what actually qualifies as a new problem. Is there a distinction between chronic conditions such as asthma and acute conditions like ear infections?

Chronic problems: For patients with chronic problems, you can bill incident to if the NPP is seeing the patient to follow through on the treatment plan and she is not making any changes to that plan. The physician must have already seen the patient for the chronic condition and set up the plan of care.

Acute problems: For patients coming in with an acute problem, if the NPP sees the patient for that acute condition, the encounter doesn’t qualify for incident-to billing. If the NPP sees the patient for the acute condition, by their very nature, treatment of these acute conditions are not incident to a physician’s service.

Recurrent conditions: If providers in your practice are seeing a patient repeatedly for acute recurrent conditions, such as recurring ear infections, whether or not an NPP’s visit for the patient who comes in again with the same acute recurrent problem qualifies as incident to will depend on the particular circumstances. It may meet the criteria if there is a formal standing order outlining the steps or changes in treatment the NPP is to follow based on defined criteria. If, however, the NPP sees a patient, say, for the third ear infection and she switches the antibiotic to a different spectrum on her own, the services are not incident to.