Incident to billing

debneas

Networker
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What would be the definition of a new problem?

The thought is: it's a new problem if the patient brings it up or the provider finds it on exam.

Example: Is a new Actinic Keratosis a new problem?

Or if diagnosed previously in another location (site), would it be an old problem?

Any help would be appreciated!
 

coloradopa

Networker
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27
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Georgia
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What would be the definition of a new problem?

The thought is: it's a new problem if the patient brings it up or the provider finds it on exam.

Example: Is a new Actinic Keratosis a new problem?

Or if diagnosed previously in another location (site), would it be an old problem?

Any help would be appreciated!

Most likely is a new problem. There are two philosophies on incident to billing. One is that the PA/NP must follow the plan as laid down by the physician on the initial visit. The other is that the after the initial physician visit the PA/NP can continue to treat as long as the physician addressed the initial problem.
For HTN method one - start patient on ACE then beta blocker and then calcium channel blocker
For HTN method two - Start patient on ACE then continue to manage therapies for target SBP 150
For the first once the PA or NP maxes out the calcium channel blocker the patient would have to return to the physician to update the plan (since the plan had been exhausted). There is a subset that believe the physician must also lay out the drugs and doses in the plan.
For the second the PA or NP can manage the HTN however they want without a return to the physician.

Now for your AK. Most likely the plan was something like cryosurgery then observe. It doesn't address what happens if a new one appears so it would need another visit from the physician or the PA/NP could bill medicare under their own UPIN and treat. If the physician put something like "if another AK is found cryotherapy unless > than 5 then photodynamic therapy". In this case the new AK would be covered and if multiples they would also be covered.
 
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I would err on the side of caution and bill under the NPP. It's only a 15% reduction in reimbursement, which isn't a huge impact when you're talking about office visits like this.
 

CatchTheWind

Guest
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Boca Raton, FL
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According to my notes (which are based on CMS's rules):

*If there is a new treatment (for the same diagnosis), but the doctor's plan of care explicitly stated that the patient might need this treatment, it is still considered incident to. Any change in plan not explicitly documented as a possibility by the doctor (even just a change in dosage) becomes a new plan of care. However, if the PA consults with the doctor about the new plan and documents that the decision to follow the new plan was made by the doctor, it can still be billed incident to.
*A new incident of the same problem (such as a new skin cancer) is considered a new problem and must be billed under the NPP. (See http://www.wpsmedicare.com/j8macpartb/resources/provider_types/mid-level-providers-qanda.shtml.)
 
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