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Midlevel providers: When and when not to bill 'incident-to'; where to find market data about reimbursement


Understand how to bill appropriately while employing NPs. Also, learn about market data for reimbursement.

Key Points

A: Incident-to care is care provided in the physician office or patient home incident to the care provided by the physician. The patient first must be seen by the physician, and the care provided must be an integral part of the physician's documented treatment plan.

Physician assistants (PAs) and NPs can bill their services as incident to the physician-that is, bill under the physician's provider number as if the physician had provided the service-as long as the services rendered to the patient are part of a documented treatment plan. Other requirements:

PAs and NPs also can bill under their own provider numbers after receiving payer credentials. Then they typically are reimbursed at 85% of the physician fee schedule.

Services to new patients by the PA or NP should be billed with the provider number of the PA or NP. Also, visits for established patients for new problems should be billed under the provider number of the PA or NP. In neither of these cases should the bill be sent out as incident to the physician service using the physician's provider number.

Incident-to services are allowed in the patient's home as well. Both the physician and the employee must be present in the patient's home for incident-to services to take place. This occurrence would be fairly rare for most practices.

There is no incident-to service in a hospital setting (inpatient or outpatient).


Q: I am negotiating to join several managed care plans. They are asking for market data to support my assertion that their reimbursement levels are too low. Where can I obtain this information?

A: One place to obtain reimbursement information is the Medicare fee schedule for your locality (presuming the services you provide are covered by Medicare). Another source is the explanation of benefit forms from your other payers.

Be aware, however, that the outliers may only want to obtain market data from you and still may be unwilling to negotiate. If that is the case, then you may be better off continuing nonparticipation with those insurers and telling patients the reason you chose not to participate. If you are not already doing so, you could offer those patients an incentive for out-of-pocket payment at the time of service. Doing so should be the policy in a small office.

The author is a consultant/trainer for gloStream, an electronic medical record/practice management company headquartered in Troy, Michigan; president of Healthcare Consulting Associates of NW Ohio Inc., Waterville; and a Medical Economics editorial consultant. She has more than 30 years of experience as a practice management consultant and also is a certified coding specialist, certified compliance officer, and certified medical assistant. Do you have a primary care-related coding question for our experts? Send it to medec@advanstar.com

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