Pulmonology Coding Alert

Question: During a new patient encounter, the nurse practitioner (NP) documented the initial history and performed the check-up. Throughout the visit, the physician was in and out of the room, but consistently available if needed.

Can we bill this visit as incident to the physician?

Michigan Subscriber

Answer: No — new patient encounters are not covered under incident-to guidelines. This is because the billing physician must initiate treatment and see the patient regularly to show they’re actively involved in the ongoing treatment of the patient’s condition. This is not possible with a new patient because a treatment plan has not yet been established. Medicare’s incident-to guidelines assume that the billing physician will perform the required aspects of the initial visit on each new patient and establish that relationship.

Similarly, new problems are also an area to watch for incident-to reporting, even if the patient is established. That is because the new problem requires a new assessment, a new evaluation, and new management or treatment of the problem. The treating physician must first establish that the problem exists and then establish a treatment plan. You could possibly report subsequent visits with an NP as incident to, provided the NP follows the treatment trajectory established by the physician during a previous visit and the physician is available on the premises. The physician must provide periodic services during the course of care. All subsequent visits cannot be delegated to the NP.