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incident to

  1. #1
    Question incident to
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    I had a NP/PA ask a question today in regards to established patients... If an established Medicare patient comes into the office and sees the NP for a change/ new problem then she would need to bill under her own provider number correct?

    The NP's example was a condition (prior treated by the physician) that was a worsening or something like angina that had become unstable. I am interested to get some feedback on this one and if anyone knows where I can find documentation that would be helpful too.

  2. Default
    It is my understanding that if it is a new problem then it is to be billed under NP number, but if it is a worsening problem that the doctor has addressed in the past it can be billed under the doctor number.

  3. #3
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    If "incident to" requirements are not met, the service must be billed under the NPP's NPI, and payment will be made at the appropriate physician fee schedule payment. For example, the service must be reported using the NPP's NPI if the NPP sees a new patient, an established patient for a new problem, or the physician (or a physician in the same group) is not physically present in the office when the NPP renders the service.

    http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

    http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf
    Last edited by RebeccaWoodward*; 02-19-2009 at 08:07 AM.

  4. #4
    Default
    Quote Originally Posted by rebeccawoodward View Post
    If "incident to" requirements are not met, the service must be billed under the NPP's NPI, and payment will be made at the appropriate physician fee schedule payment. For example, the service must be reported using the NPP's NPI if the NPP sees a new patient, an established patient for a new problem, or the physician (or a physician in the same group) is not physically present in the office when the NPP renders the service.

    http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

    http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf
    This topic really interests me .... the practice I currently work for "thought" they were billing their NPP visit under the incident to rules but we just found out they are not, all the charges for the NPP that were working here prior to me are being billed out under their own numbers, the problem occurred when we recently hired another Pa and a NPP all their charges except Medicare and Capital Blue were being billed as incident to! We have been "schooled" by our corporate coders that this was incorrect. Just as your reply states Rebecca, so we are now in the process of having our records reviewed by our corporate coders to make sure the incident to rules were met on the services we did bill under incident to.

    I asked the NPP and Pa to indicate on the chargeslip for billing purposes if the visit was incident to and one of them told me she doesn't understand these rules, in essence she really does only see "acute" patients the day of, so I am likely to state that the majority of her services would not fall under incident to,unless it's one of their chronic problems or a f/u of something they have recently seen a MD for.

    This is such a sticky topic in my opinion it makes for alot of work on our part as the biller/coder to verify if the visit is incident to or not when the provider herself isn't clear on the guidelines....

    Sorry for going on and on....
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  5. #5
    Default incident to
    Quote Originally Posted by rthames052006 View Post
    This topic really interests me .... the practice I currently work for "thought" they were billing their NPP visit under the incident to rules but we just found out they are not, all the charges for the NPP that were working here prior to me are being billed out under their own numbers, the problem occurred when we recently hired another Pa and a NPP all their charges except Medicare and Capital Blue were being billed as incident to! We have been "schooled" by our corporate coders that this was incorrect. Just as your reply states Rebecca, so we are now in the process of having our records reviewed by our corporate coders to make sure the incident to rules were met on the services we did bill under incident to.

    I asked the NPP and Pa to indicate on the chargeslip for billing purposes if the visit was incident to and one of them told me she doesn't understand these rules, in essence she really does only see "acute" patients the day of, so I am likely to state that the majority of her services would not fall under incident to,unless it's one of their chronic problems or a f/u of something they have recently seen a MD for.

    This is such a sticky topic in my opinion it makes for alot of work on our part as the biller/coder to verify if the visit is incident to or not when the provider herself isn't clear on the guidelines....

    Sorry for going on and on....
    Your right, this is a sticky subject, also remember that some insurance carriers will not accept NP, PA's if they are not billed incident to. This just gets better and better!!! LOL. We've ran into the same issues. We also asked the PA's to indicate on the encounter form if incident to.

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