Wiki Incident to billing - Medicare policy

[jliving77]

I am trying to explain the rules of incident to billing to the medical staff and scheduler at my clinic and I am running into conflicting explanations on this rule.
An article I found at http://aafp.org states "Although some local carriers also require the physician to see established patients each time they present with a new symptom national Medicare policy does not require this."
The conflicting information I am seeing comes from the AAPC which states "New patients, or those with a new problem, cannot be seen incident to." I know that new patients cannot be seen but what I need to verify is if an established patient has a new issue, and we can only schedule with a non-contracted provider, is that provider allowed to determine how to treat that patient's problem? This also presents a problem as such that the scheduler may not know why the patient needs to come in. They don't ask clinical questions and the patients may also not be comfortable discussing this with them.
Can anyone tell me what they do in their office or tell me where I can find more material on this? I would like to give the staff the information as soon as possible as we have an issue with new patients continuing to be scheduled with the non-contracted providers even though I have told them many times not to do that!
Thanks much,
Jennifer

 

[jlund1]

I live in Nebraska, our MAC states that incident to is only allowed if the APC (example PA, APRN) is following the initial plan of care by the Provider. If that patient was scheduled with out PA for incident to but during the visit a new problem or new treatment plan was started we will bill under that PA and not the MD. Now the MD can come into the office and see the patient and establish a new plan of care and in order to bill that visit under the MD he must personal perform (and document) the majority of the visit.

http://www.wpsmedicare.com/j5macpartb/resources/provider_types/2009_0803_incident.shtml

http://wpsmedicare.com/j5macpartb/t...es/2013-0723-incident-to-services-handout.pdf

Thanks!

 

[pamsbill]

"... if an established patient has a new issue, and we can only schedule with a non-contracted provider, is that provider allowed to determine how to treat that patient's problem?"

I am a little concerned about this question. What do you mean by a non-contracted provider? "Incident to" is strictly for use by mid-level providers. I just want to make sure you are not billing a physician under another physician using "incident to."

Once a visit no longer qualifies as "incident to" then it must be billed under the mid-level's NPI and PTAN. So if a new problem is introduced during an office visit, then the mid-level needs to understand the visit no longer meets the criteria to be able to be billed under the supervising physician.

Our mid-levels all have their own provider numbers and determine which visits meet the criteria for "incident to."

When I explain the concept to providers, I explain that as long as the mid-level (NP or PA or even RN in certain instances) is acting as an extension of the physician and not making any clinical decisions on his/her own, it might meet the criteria. The mid-level must be following an established plan of care (which rules out new patients and new problems) and a physician must be on site to step in if necessary. Otherwise, the visit must be billed under the mid-level.

I have never seen any guidance from any Medicare carrier stating Medicare policy allows mid-levels to see new problems and still treat the visit as incident to.

 

[vperez1]

Incident to billing

pamsbill: For clarification can a mid-level (NP or PA) see a New Patient billed under the mid-level's NPI and PTAN? Either way where can I get documentation?