Wiki incident to when there is a new diagnosis

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CatchTheWind

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A patient sees the PA for follow-up on a the doctor's diagnosis and plan, but during the visit the PA diagnoses a new, unrelated condition. My understanding is that the visit cannot be billed incident to, but the doctors are giving me a hard time, stating that what matters is the condition the patient came in for. Who is right?

And another issue: The PA saw the patient for a suspicious lesion and did a skin biopsy. The result was skin cancer. So the PA documented his plan of care, the doctor signed off on it, and now the PA is excising the lesion. Can this be billed incident to because the doctor signed off on the plan of care???

Can you provide sources that I can bring to the doctors? Thanks!
 
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The exact language of the CMS 'incident to' regulations can be found in the Medicare Benefit Policy Manual, Chapter 15, section 60, linked below. In particular, see section 60.2, quoted here, that addresses 'incident to' as pertains to services provided by a PA, and which clearly says that the course of treatment must have been initiated by the physician by a 'direct, personal, professional service'. Any legal language such as this is, of course, subject to interpretation, but per my understanding, signing off on a note, in and of itself, does not constitute a personal professional service.

A nonphysician practitioner such as a physician assistant or a nurse practitioner may be licensed under State law to perform a specific medical procedure and may be able (see §§190 or 200, respectively) to perform the procedure without physician supervision and have the service separately covered and paid for by Medicare as a physician assistant’s or nurse practitioner’s service. However, in order to have that same service covered as incident to the services of a physician, it must be performed under the direct supervision of the physician as an integral part of the physician’s personal in-office service. As explained in §60.1, this does not mean that each occasion of an incidental service performed by a nonphysician practitioner must always be the occasion of a service actually rendered by the physician. It does mean that there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the nonphysician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment. In addition, the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary.

 
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