Incident-to billing: Clearing up the confusion

Incident-to billing is a way of billing outpatient services (rendered in a physician’s office located in a separate office or in an institution, or in a patient’s home) provided by a non-physician practitioner (NPP) such as a nurse practitioner (NP), physician assistant (PA), or other non-physician provider. Incident-to billing can be confusing. This article, consisting of questions from Medical Economics readers, will help demystify how incident-to billing works.

Q: We plan on billing incident-to as we are on site and available to the NPs at all times. If we plan to bill under the MD’s PIN at all times, do we need to credential and also enroll the NPs with CMS, Medicaid and other insurances?

A: I understand wanting to maximize revenue by billing under your physician’s Provider Identification Number (PIN).  However, I would be cautious with the idea of billing this way all the time.  There will be instances when the NPP will need to bill under his/her own PIN, as I’ve detailed below.

First, when an NPP sees a patient for a new problem, he/she will need to bill under his/her own PIN.  Incident-to guidelines do not allow an NPP to bill incident-to a physician’s services (i.e., under the physician’s PIN) when a new problem is addressed.  This could happen in a situation when the patient was scheduled to be seen for an established problem but brings up a new problem during the course of the visit.  Once a new problem is introduced, the visit would need to be billed under the NPP’s PIN, not the physician’s PIN.

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Also, keep in mind that incident-to guidelines were developed by Medicare, and other insurance carriers do not necessarily follow Medicare’s lead.  For example, in our area of the country, Anthem not only hasn’t adopted Medicare’s incident-to guidelines, it has put in place a guideline that requires all practitioners (physicians, nurse practitioners and physician assistants) to bill under their own PIN.  In fact, there is only one payer in our region besides Medicare that has adopted incident-to guidelines. 

So it is important to check with each of your carriers before billing services incident-to.

And, it is very important that each of your mid-level providers receives his/her own National Provider Identifier (NPI) and be credentialed with each payer to bill under his/her PIN number, if the situation warrants. 

Next: How often does the physician need to see the patient for the NP to consider it incident-to?

Q: How often does the physician need to see the patient for the NP to still consider it incident-to?

A: For incident-to services to continue to be billed, Medicare has stipulated that the physician must perform subsequent services that reflect his/her continued active participation in and management of the patient’s care.  A specific time frame of physician involvement and management is not stipulated but is left to the physician’s medical judgment based on the patient’s condition and needs.

Q: If the physician sees a new patient briefly after the NP has seen the patient for a physical, does this qualify for further incident-to billing at subsequent visits with the NP or does the physician need to see the patient independently?

A: I need to clarify that the initial problem-focused patient visit (CPT codes 99201-99205) cannot be split or shared between the NPP and physician in order to bill incident-to follow-up visits.  The physician must independently see the patient and establish a plan of care for the condition.

The scenario you presented includes a preventive exam (99381-99387, 99391-99397) and a problem-focused service (99211-99215) during the same encounter, which must be billed on the same claim, appending Modifier 25 (Significant, separately identifiable Evaluation and Management (E/M) service by the same physician or other qualified healthcare professional on the same day of the procedure or other service) to the E/M code.  

Since these two services must be billed together on a claim, they need to have been performed by the same practitioner.

Q: Is the Physician Assistant to be listed as the rendering provider? If so, how will CMS know the billing is incident-to?

A: According to Medicare’s National Coverage Determination (NCD), Incident to a Physician’s Professional Service in the Office or Clinic, “When billing incident to services, the claim should be submitted as if the physician personally performed the service.“ 

Therefore, the NPP is not listed on the claim form.

Also, according to the Medicare Claims Processing Manual, Chapter 26, Section 10.4, based on who was the supervising physician on the date of service being billed, there are two ways of filling out the claim form:

The “ordering physician” is the physician who initially saw the patient and established the plan of care, which the NPP followed during today’s subsequent visit being billed.

The “supervising physician” is the physician who was on-site and available to the NPP during the visit being billed.  Since the supervising physician can be different than the ordering physician, he/she needs to be identified on the form.

On the new CMS 1500 claim form, Version 02/12, instructions now include that Qualifier DK needs to be added to the left of the physician name listed in Item 17 to indicate that he/she was the “ordering provider.”  Additionally, the new instructions also say to leave 17a blank.

Next: Billing incident-to if the physician is off-site

Q: If the physician is off-site, can the PA see patients in the office and bill for services rendered under his or her NPI?

A: If you have only one physician in your office, then you would be correct, when the payer credentials PA’s (Physician Assistants) or NPP’s.

If the physician is off-site (i.e., outside the office suite and not able to provide direct supervision), the PA would need to bill under his/her own NPI, when possible. If the payer doesn’t credential NPPs, the claim would be billed under the physician’s NPI/PIN even if incident-to requirements have not been met.

If you have more than one physician in your practice and neither is in the office suite when the services are rendered, you would also be correct that the claim would need to be billed under the NPP’s NPI/PIN, if the NPP is credentialed by the payer.

If you have a physician in the suite who is supervising the NPP, even if he/she is not the original ordering physician, the service can be billed incident-to and billed with the ordering physician’s name and NPI in Items 17 and 17b, respectively, and the supervising physician’s signature in Item 31.

Q: If the physician is on-site, can the PA bill under the physician’s NPI only if it is an “incident to” situation?

A: If a physician is on-site, the PA can bill under that physician’s NPI/PIN as incident-to, if the payer recognizes incident-to guidelines. 

If the payer does not recognize incident-to guidelines, the PA would bill under his/her own NPI/PIN (if credentialed) and under the physician’s NPI (if the PA is not credentialed). 

Answers to readers' questions were provided by Renee Dowling, a billing and coding consultant with VEI Consulting Services in Indianapolis, Indiana. Send your coding questions to medec@advanstar.com.