Wiki What qualifies as a "change" in the plan of care for Outpatient Incident-To Billing Rules?


Charleston, WV
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Hello Everyone! 🙂

Soo.... Incident-to Billing can be tricky, as even references sometimes vary in their wording/ interpretation of the rules. It has been to my understanding that any time a change is made in the physician's current plan of care, it no longer qualifies as incident-to services for billing purposes. However, I have heard mixed information on what is considered a "change." As always, advice and suggestions are appreciated.


1) Initial Visit: Patient is evaluated in an outpatient setting by a physician and is found to have osteoarthritis of the right knee. Treatment options are discussed in detail with the patient, including different types of injections (Depo-Medrol, Kenalog, etc) and exercises, as well as surgery as a last resort.

2) Second Visit: Patient is seen in follow-up by the the PA for osteoarthritis of the right knee and has decided to try an injection of Depo-Medrol, as previously discussed by the physician in the initial visit. The PA administers the injection.

The injection had already been discussed in the physician's plan of care, but was administered by the PA. Still incident-to? If so, please consider the next option.

3 )Third Visit: Patient is seen in follow-up three months later by the PA for osteoarthritis of the right knee, as the previous injection did not help. The PA had decided to either increase the dosage of Depo-Medrol or to try Kenalog instead.
Again, the injection had already been discussed in the physician's plan of care, but the dosage and drug change was at the discretion of the PA. Still incident-to?

Thank YOU in advance,
The official guidance on a question such as this is vague at best.

Personally, I don't see anything in what you've described above that would immediately disqualify the second or third visit from being billed as 'incident to'. The PA is working within the care plan, and the only thing that could perhaps be challenged is the change in dosage in the third visit, however if the physician did not specify dosages in the initial plan, or documented that the PA could titrate the dose as needed, then I don't see why that wouldn't be considered still 'incident to'.

I wouldn't over-think this. When payers conduct audits of this kind of thing, they're looking for widespread abuses that are costing them significant amounts of money - they aren't looking to pick a fight over different ways of interpreting the grey areas on individual encounters.

Here's the approach I take in a situation like this: if you know the 'incident to' rules well and feel you can write a few sentences of a rebuttal to an auditor explaining why you believe it qualifies as 'incident to', then I would go ahead and bill it that way. If you can't, then don't. Or, if your practice wants to play it safe and not take any chances, and doesn't want its coders spending a lot of time looking at notes and trying to decide what to do, then it might be better just to not bill 'incident to' at all - I know that a lot of practices take this approach because they've decided the extra 15% payment they might get isn't really worth the amount of headache and risk involved.
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