Understand incident-to: 6 tips when billing for time spent

September 25, 2016

The question keeps coming up as to whether my nurse practitioner can bill incident-to while counseling patients and bill based on time spent counseling. I get mixed reports on this. What is the answer? Can they bill by time?

Q: The question keeps coming up as to whether  my nurse practitioner can bill incident-to while counseling patients and bill based on time spent counseling. I get mixed reports on this. What is the answer? Can they bill by time?

A: According to Medicare, the nurse practitioner cannot bill based on time when performing services “incident-to.” It may not make much sense, given that they can perform the same services as physicians relative to history, exam and decision-making, while practicing in the room next to you, independent save for the overall constraints of incident-to. But that is where Medicare has come down on this question.

In the March 2016 update to the Medicare Claims Processing Manual Chapter 12 you will find the following guidance):  

  • Selection of Level of Evaluation and Management Service Based On Duration of Coordination of Care and/or Counseling Advises physicians that when counseling and/or coordination of care dominates (more than 50%) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service.   

  • The time spent in counseling/coordination of care and medical decision-making will determine the level of service billed. The code selection is based on the total time of the face-to-face encounter or floor time, not just the counseling time. 

  • The medical record must be documented in sufficient detail to justify the selection of the specific code if time is the basis for selection of the code. 

  • In the office and other outpatient settings, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported.   

  • Face-to-face time refers to the time with the physician only. 

  • Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided. The last three points  respond directly to your question. This position is somewhat at odds with the direction that healthcare is taking with both CMS and the American Medical Association talking about silos of care with multiple provider types contributing to a patient’s overall care and with a variety of provider types working to the highest degree of their licensure. Nurse  practitioners can bill by time when they bill in their own name and NPI number. 

The general trend is towards more of this kind of thing rather than less. But remember that this is Medicare (and likely all governmental programs.) It is unusual for commercial payers to say much at all about incident-to, much less at this level.