Incident-to billing: Your coding questions answered

Renee DowlingQ: Can a new patient be seen initially for history taking, measurements and vitals before the physician sees the patient and still be considered “incident-to”? Or does the physician have to conduct the information gathering?

A: In an incident-to situation, the physician must conduct the initial visit and establish the plan of care for a condition in order for a nurse practitioner (NP) or physician assistant (PA) to treat that condition during follow-up visits.

However, the Evaluation and Management guidelines say that it is appropriate for ancillary staff to document the review of systems (ROS) and past family and social history (PFSH), so long as the physician or non-physician practitioner (NPP) confirms or supplements the information. 

READ: Clearing up the confusion surrounding incident-to billing

Keep in mind that this can also apply when an established patient is seen for a new problem. In these instances, the ROS and PFSH do not need to be recorded again if there is evidence that the physician reviewed and updated the previous information. The review and update can be documented by:

• describing any new ROS and/or PFSH information or noting there has been no change in the information, and

• noting the date and location of the earlier ROS and/or PFSH.

Our local Medicare carrier, Wisconsin Physician Services (WPS) also allows ancillary staff to document the chief complaint. So it’s important to check with your regional Medicare carrier to see if they allow this.

Next: Why it's important for PAs to have provider identification numbers

Q: Is it a requirement that PA have their own provider identification number (PIN) for the physician to bill incident-to if all the guidelines are met?

A: I understand that not credentialing a PA might be easier for your office; however, a PA should be credentialed along with all of your providers. The reasons are many.

First, an insurance company could recoup the money for a claim when it is billed incident-to physician services if the PA is not credentialed. Payers do not like paying for services rendered by a non-credentialed practitioner. When a provider is credentialed, he/she attests that the services provided and billed are appropriate according to the signed contract. Second, it will be necessary at times for the PA to bill his/her services directly. For example,

• if a physician is not in the office suite and the PA needs to see a new or established Medicare (or other payer that follows incident-to guidelines) patient with a new or established plan of care;

• if the PA sees a patient with a physician-established plan of care; however, the patient has a new problem for which a plan of care has not been established; or

• if the PA sees a patient with insurance that does not recognize incident-to billing and requires the provider who performed the service to bill (i.e., an Anthem patient).

While it seems simpler to not credential an NPP, it could create costly problems down the road.

Read more advice from our coding and billing experts

Answers to readers' questions were provided by Renee Dowling, a billing and coding consultant with VEI Consulting Services in Indianapolis, Indiana. Send your coding and billing questions to [email protected].