Urology Coding Alert

Question: We bill for a nurse practitioner who does initial consultations in our office only with a physician on premise. We bill for the visit under supervising physician to all carriers including Medicare. She has reassigned her benefits to them. Is this correct?


South Carolina Subscriber


Answer: Unfortunately, with Medicare, your nurse practitioner cannot bill a consultation incident to the physician (under the physician's number). One of the requirements for incident-to billing is that your physician must establish a plan of care to be followed before your nurse practitioner can bill incident to. But in your case a physician had not established a plan of care before or when your nurse practitioner performed a consultation. However, the only way your nurse practitioner can bill a consultation is under his or her own provider number.

How it works: When a nonphysician practitioner (NPP), such as a nurse practitioner, performs a service incident to a physician, the office can bill under the physician's Medicare number and secure 100 percent reimbursement.

But if the NPP does not provide services incident to the physician, you must bill under the NPP's number --meaning you receive 85 percent reimbursement for the same service instead of the full 100 percent.

Bottom line: If the physician has not established a plan of care, incident-to billing is impossible. The meaning of incident-to is that an established patient is seen by an NPP who is following a prescribed course of treatment determined by the physician, and the patient is presenting for follow-up care in the office.

Example: An NPP sees an established patient in the office to check on the patient's urinary tract infection symptoms (99212, Office or other outpatient visit for the evaluation and management of an established patient ...). The physician is in the office supervising but does not see the patient.

In this instance, incident-to requirements were met; this is an established patient with an established problem and plan of care, and the physician is in the office. Therefore, you may bill incident-to the physician using the physician's PIN for the NPP's service. You'll receive 100 percent reimbursement of the global.

Note: Incident-to billing is a Medicare policy and is not followed by most other insurance carriers. Most private or non-Medicare carriers usually do not credential NPPs, such as a nurse practitioner, and consequently will pay for their services only when you report them in the physician's name. With these carriers the nurse practitioner can bill for the consultation in the doctor's name as long as the physician provides general supervision as explained above. However, check with your non-Medicare carriers as to how they wish you to report your NPP's services and whether they follow an incident-to policy.