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Incident-To Billing Question...

  1. #1
    Question Incident-To Billing Question...
    Medical Coding Books
    We have a Nurse Practitioner who provides Diabetes Evaluations and follow-up Diabetes Management services. She works within our Endocrinology Department of a multi-specialty group practice. She has an Endocrinology Supervising Physician and would be billing Medicare using that physician's name. Please read the scenario and verify if we are meeting Medicare's Incident-to Guidelines.

    There is a documented order from the Ordering primary care physician (who is within our group practice) stating they have requested Jane Doe, NP to evaluate and manage the patient's DM condition. However the order is very general ("evaluate and manage the pt's DM Condition"). The NP office notes are signed off by the Endocrinology Supervising Provider who is in the suite at the time of service. The NP notes are also reviewed by the original Ordering Physician, and the patient has frequent follow-up visits for the DM condition with the Ordering Physician.
    We would like to know if this arrangement meets "Incident-To" guidelines. Would an "order" meet the "plan of care" requirement? If so, can we bill the claim with the Supervising Physician's name, and the Ordering Physician's name be the Referring Provider?
    Thank you.
    Last edited by kkraus1; 03-29-2010 at 03:28 PM.

  2. #2
    Evansville Indiana
    Default incident to
    Does the physician see the patient, diagnose the DM and initiate a treatment plan before the NP sees them?

  3. #3
    No. He is only "supervising". The initial diagnosis was made by the Primary Care Physician (who is within our group). The Primary Care physician has an order in their notes for the patient to be followed by the nurse practitioner for DM evaluation and management.

  4. #4
    Milwaukee WI
    Default Not
    If I'm understanding your scenario correctly, I'd vote, No, this is not incident to.

    The PCP is transfering care to the endocrinology specialty and the Endo NP is the provider. First visit can be new patient if this is a recognized different specialty. All visits would be billed under NP name/NPI. (Unless, of course, patient actually saw the MD.)

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 04-05-2010 at 03:32 PM.

  5. #5
    Jacksonville, FL River City Chapter
    I agree. The incident to rules say that "there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the nonphysician practitioner is an
    incidental part..."

    The physician has not rendered a "direct, personal" service "to initiate the course of treatment." They just gave an order to an NPP saying "Here. You take them." This is different than the physician seeing the patient first, and then passing them over to an NPP for subsequent care with an MD-authored management plan in hand for the NPP to refer to.

    Seth Canterbury, CPC, ACS-EM

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