What active patient management means when billing incident-to

June 25, 2016

How often must the physician perform subsequent services that reflect the continued active management of a patient’s care in order to bill incident-to?

Q: How often must the physician perform subsequent services that reflect the continued active management of a patient’s care in order to bill incident-to?

A: One of the incident-to requirements is that the “services rendered are part of a course of treatment during which the physician personally performs the initial service and is actively involved in the course of treatment.” The key words here, for your question, are “actively involved.” What, exactly, does that mean?

Many years ago there were guidelines that specified that the provider needed to see the patient him/herself every third visit—and variations on that theme. Those specific guidelines are long gone, and what we are left with is this less specific language. 

Other parts of the incident-to guidelines bear on this question. Was a plan of care developed, and is the problem being addressed by the non-physician provider (NPP) part of the overall plan of care developed by the physician? Is the physician treating or directing care for the underlying condition for which treatment is provided today by the NPP?

So it’s not so much a ‘how long has it been’ since the patient has been seen by the physician, it is now more of documenting the physician’s involvement in the plan. This is consistent with the collaborative type models of care that Medicare envisions for the future of primary care and chronic disease management. 

As in the case of chronic care management codes and other services where auxiliary or NPP staff participate, let your electronic health record reflect the overall management of the physician

 

Q: We have a physician that does things his own way, from notes to codes to overriding charges. One is enough, but others see what he does and want to do it too. What can we do rein him in?

A: This question is a little outside the bounds of coding—but could fall into the compliance category, depending on the nature and extent of his “variances.”

When compliance came to the physician side of healthcare, and the Office of the Inspector General produced its Compliance Guidance for Physician Practices, they made it clear that compliance programs were to detect and prevent violations of the law. There were specific risk areas identified–coding and billing chief among them. 

So if your provider’s “own ways” do not align with the general principles of medical record documentation, with correct coding guidance or with current guidance on cloning or other EHR concerns, then you may have an actionable item with which to approach him. 

We all know folks who are characters and generally ornery, but if there is no actual rule or guideline being breached, then it is on your group to develop internal policies for policing such concerns.