Coding Insights: Can this encounter be billed Incident-To?

Coding and billing advice from the experts

Q: If an nurse practitioner or physician assistant gathers the history and other information and the physician then examines the patient and establishes assessment and plan, does this qualify for incident-to billing even if a new problem comes up?

A: In the situation that you described, incident-to guidelines would not necessarily apply, depending on which part(s) of the history the nurse practitioner (NP) or physician assistant (PA) documents. Per Evaluation and Management Guidelines, “The review of systems (ROS) and/or past, family and social history (PFSH) may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.”

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Therefore, as long as the NP or PA does not document the history of present illness (HPI), the visit should be billed under the physician’s National Provider Identifier (NPI).

However, if an NP or PA documents more than the ROS and/or PFSH, the documentation would not support incident-to requirements.

According to the Centers for Medicare & Medicaid Services (CMS), to be covered incident-to the services of a physician or other practitioner, services and supplies must be:

  • an integral, although incidental, part of the physician’s professional service,

  • commonly rendered without charge or included in the physician’s bill,

  • of a type that are commonly furnished in physician’s offices or clinic,

  • furnished by the physician or by auxiliary personnel and under the physician’s direct supervision

According to CMS, “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, and there must be subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment. In addition, the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary.”

This means that a physician individually must have diagnosed a medical problem and established a course of treatment, which the NP or PA would follow during subsequent visits.

If the patient presents for a subsequent visit for treatment of the diagnosis for which the physician established the course of treatment and a new problem, incident-to guidelines would not apply because the physician has not diagnosed the new problem and established a course of treatment.

In this situation, the NP or PA would be required to bill the visit under his/her own NPI, for which he/she would be reimbursed at 85% of the Medicare Physician Fee Schedule.

The answer to the reader’s question was provided by Renee Dowling, a billing and coding consultant with VEI Consulting in Indianapolis, Indiana. Send your billing and coding questions to

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