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Thread: Incident To

  1. #1

    Default Incident To

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    If a NP or PA sees and existing patient that has previously qualified as Incident to, and is seeing them for their chronic conditions that the Physician has created a treatement plan for, and the patient mentions a new problem, like sinusitis, does the PA or NP still have to bill it out as non incident to, even though they are still treating the patient for all their chronic conditions at the same time?

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    If they address the new problem then the visit must be billed under the NPP, to bill under the physician you will have to do so as a shared encounter, the physician would have see and the patient and provide his own assessment of the condition.

  3. #3
    Join Date
    Apr 2007
    Kokomo, IN

    Default controversial

    This is a controversial issue. Some say it must be incident to, some say it must be under NPP's NPI. There isn't a definitive answer yet. Here's one article with this very issue. See what you think. As I said, not everyone will agree. So, until CMS clarifies it's left to interpretation (again)!!!

    Incident-to Billing -- Appropriate Use
    A physician evaluates a patient and diagnoses hypertension. The physician initiates treatment. The physician employs an NP. The NP conducts follow-up visits with the patient, monitoring and treating the hypertension over weeks, months, or years. The physician sees the patient every third visit, under a policy adopted by the practice. The NP's work may be billed under the physician's provider number, and the practice will receive 100% of the physician's fee schedule rate for the services performed by the NP.

    Incident-to Billing -- Appropriate Use Unclear
    If the scenario described above continued, but one day the hypertensive patient arrived for a follow-up visit with the NP and announced a new complaint of sinusitis, for example, it is not clear that incident-to billing would be appropriate. There are differing interpretations among clinicians and auditors of the phrase "the physician must perform the initial service," found in the "incident-to" rules. Some clinicians may interpret this rule to mean that only the first visit to the practice must be conducted by the physician. Others interpret "perform the initial service" to mean that when there is a new problem, the NP must either bill under his or her own number or refer the patient back to the physician. The Centers for Medicare & Medicaid Services (CMS) has not defined "initial service." Neither has CMS clarified the phrase "subsequent services of a frequency which reflect [the physician's] active participation in the management of the course of treatment." "Active participation" may mean different things to different clinicians, auditors, and administrators. For example, active participation may mean chart review, or face-to-face visits, depending upon the reader's interpretation.

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