Coding Consult

December 2, 2005

Incident to services

First, the basics: You can bill Medicare under your NP's or PA's Medicare provider identification number for services she renders and receive 85 percent of your normal fee. Or, preferably, you can bill the services "incident to" your own and under your own number, and get 100 percent. But to do this, you have to meet specific criteria that many doctors find confusing.

We turned to our experts to help you break down Medicare's incident-to guidelines so you can spot appropriate opportunities to get a physician-rate payment for your midlevel's services.

Medicare's incident-to guidelines state that you, the physician, must see the new patient and institute a plan of care before the NP or PA can follow up with the patient, says Mary Falbo, a certified coder and president of Millennium Healthcare Consulting in Lansdale, PA. To see how this works, consider these two scenarios:

Scenario A: A 70-year-old patient sees you for an initial visit to manage his uncontrolled Type II diabetes and related peripheral circulatory disorders. After this visit, he has a follow-up appointment with your NP one week later to discuss any adverse reactions to the insulin.

Because the NP is carrying out your established treatment plan, you can report the appropriate E&M code (99211-99215) under your PIN for the follow-up. List ICD-9-CM code 250.72 (diabetes mellitus; diabetes with peripheral circulatory disorders; Type II or unspecified type, uncontrolled) as the reason for the visit.

Scenario B: The same patient schedules an initial visit with you, but calls the office a few days before his appointment, complaining of chest pains. Because of a heavy schedule, you're unable to treat the patient, and the NP sees him instead. Your NP evaluates the patient and performs an ECG.

In this case, you must bill this encounter under the NP's PIN, says Carol Pohlig, a senior coding specialist in the Department of Medicine at the University of Pennsylvania Medical Center in Philadelphia. Because you didn't provide the initial service and establish a plan of care for any of the patient's medical problems, this office visit doesn't meet Medicare's incident-to guidelines, she says. Report the office visit (99201-99205) and code 93000 (electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) for the ECG and 786.50 (chest pain, unspecified) for the symptom that led to the services.

Direct supervision's a must

Another important incident-to billing requirement is that the NP or PA must provide the services under your "direct supervision." "This doesn't mean that the physician must be present in the same room with the NP or PA," Falbo clarifies. Rather, you must be in the office suite and immediately available to provide assistance and direction, she says.

Make sure that you note in the patient's chart that you were in the office when the NP or PA performed the services, Pohlig suggests.

When the physician who supervises the NP's or PA's services isn't the same doctor who ordered the initial services or laid out the patient's treatment plan, you might be confused about whose PIN you should bill under. Our experts say that you should always bill under the supervising physician's PIN.