Mid-level or Professional Charge
Hi Melissa, I have enclosed a short article for your review. As a compliance officer I would recommend that the examination performed by the mid-level provider be billed as such.
Evaluation & Management (E/M) Articles: Incident to Service Guidelines Print Bookmark Novitas Solutions Medical Review (MR) Department has observed a recent trend of the utilization of non-physician practitioners to perform initial office visits as incident to services. Documentation reviewed by the MR Department indicates that a non-physician practitioner performs the initial visit and the supervising physician documents a note in the medical record similar to the following:
“Nurse practitioner performed the history and physical and I was present for the entire encounter and my treatment plan is as follows……�
This is incorrect use of the non-physician practitioner and incorrect billing under the incident to guidelines. This article will explain the Medicare definition of incident to services and the criteria that must be met to properly bill incident to services.
CMS defines incident to services as “services or supplies are furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness.�
In order to be covered as incident to the physician's service, the following criteria must be met:
•services must be an integral, although incidental, part of the physician's professional service,
•commonly rendered without charge or included in the physician's bill,
•of a type that are commonly furnished in physician's offices or clinics, and
•furnished by the physician or by auxiliary personnel under the physician's direct supervision
Incident to services must be performed under the direct supervision of the physician. CMS directs that “Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.�
CMS further indicates, under direct supervision, “This does not mean, however, that to be considered incident to, each occasion of service by auxiliary personnel (or the furnishing of a supply) need also always be the occasion of the actual rendition of a personal professional service by the physician. Such a service or supply could be considered to be incident to when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflects his/her active participation in and management of the course of treatment.�
An initial history and physical performed by a non-physician practitioner, although the physician is documented as being in the room, is not covered under these guidelines. As underlined above, the physician must perform the initial service. This includes the history and physical and examination portion of the service, not only the treatment plan. Therefore, it is expected that the physician will perform the initial visit on each new patient to establish the physician-patient relationship.
Providers billing initial office visits as incident to when the initial history and physical is performed by a non-physician practitioner will have those claims denied by Novitas Medical Review.
Also note that hospital and skilled nursing facility services cannot be billed as incident to at any time. For more information and direction on incident to services, refer to CMS' Internet-Only Manual (IOM) Publication 100-02, Chapter 15, Section 60.