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Incident To Documentation

  1. Question Incident To Documentation
    Medical Coding Books
    In an article about the Medical Review for "Incident To" services conducted by Part B it mentioned that one of the errors they found in documentation was that the E&M servies that were docemented by the PA; there was no indication that the physician was present in the office and/or that there was physician involvement in the patient's care. Would the signature of the physician on the note after reviewing and the fact that they were seeing patients in the office at the same time be sufficient enough or would a statement by the PA or physician be more efficient stating that they were physically present and that they are following the physicians course of treatment?


  2. #2
    Columbia, MO
    The physician signing the note is insufficient for incident to billing. The important piece of documentation is that the patient is here for a followup from a visit with the physician for the same issue, and of course that the physician is in fact on site at the time. Fro a shared encounter they state that for established patients you may bill under the physician if the NPP and the physician share the patient. ...." however if there is no face to face encounter by the physician on the same day ( even if the physician signs off on the documentation provided) the visit must be billed under the NPP. The AMA recently discussed this same issue and gave examples of acceptable documentation by the physician. they must state they have personally seen and examined the patient and then any relevant findings from that examination.
    I hope this helps.

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