Wiki Compliance Issue: NP and Physician E/M Services

Ozbaby

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Per CMS new patient services must be personally performed by a physician with the exception of history obtained by ancillary staff.
If a nurse practitioner sees a new patient in the office to obtain the history and perform an examination but then passes the encounter off to a physician who conducts a pertinent exam (one body system/part) and determine the A/P, does this suffice as “personally performed?”
It is essentially a split/shared service in an outpatient office that is being performed. Does the physician need to do the entire E/M themselves or can the elements be divided between the physician and NP?
 
  • In the office setting when the physician performs the E/M service the service must be reported using the physician’s NPI.


  • When an E/M service is a shared/split encounter between a physician and a NPP 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 NPI, and payment will be made at the appropriate physician fee schedule payment amount.

So for your scenario you will need to determine if incident to guidelines were met (established plan of care, etc). If yes, ok to bill under the physician. If no, then the account would be billed under the NPP. If the patient is a new patient then incident to would not apply and the claim would be billed under the NPP.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf
 
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Not incident to

I agree with all you pointed out and I thank you for replying. I know the services do not meet incident to guidelines and the split/shared doesn’t apply in an office setting - it’s my providers I’m convincing. They believe the NP can do the bulk of the E/M service while the physician comes in at the end to “examine” what is pertinent, agree with the NP and document an A/P. We’ve gone a few rounds over this topic and I want to get others to weigh in as you have. Thank you again.
 
I agree with you and with Chelle's post above; a new patient visit could never be billed as 'incident to' if the NP is doing the 'bulk' of the work. This can be a confusing concept for providers, but an easy way to explain it is that an 'incident to' service simply means that it is a service that is carried out on behalf of a physician and under their orders. Whether it is the office staff or a hospital or lab or surgery center, or in this case, a mid-level provider, 'incident to' just means that these people are carrying out the instructions that the physician has set up for the patient, and not making any independent medical evaluations or decisions of their own - they are just acting as the eyes, ears and arms of the physician. Once a mid-level provider takes the initiative to evaluate a new patient, or a new problem in an established patient, or to start making any changes to a plan or ordering new services that weren't part of the original care plan, then it is no longer an 'incident to' service and can't be billed as having been done by the physician. 'Incident to' does not just mean 'supervised' or 'approved' by the physician, it also means that the services are performed at the order of the physician. Obviously, an NP's HPI could not have been ordered by the physician if the patient is new and the physician did not see them until afterwards. Hope that helps some.
 
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