NP, PA incident-to billing: What is (and isn’t) allowed

Ray Painter, MD

Mark Painter

I have a physician assistant working for me. My billing staff and I are in disagreement as to how we should charge “incident to;” can you help?

The issue of billing for services provided by the advanced-practice provider (APP) is a complex one. We will try and boil it down.

First, we will remind everyone that “incident to” services can only be provided in the office setting and require that the billing provider is in the facility and not otherwise engaged in a way that will prevent the billing provider from assisting with the patient when the “incident to” service is provided.

Also by Painters: Is there a silver lining to value-based pay initiatives?

An APP (PA or NP) can report services “incident to” an MD under a few circumstances:

• A service is provided in the office setting during which both an APP and an MD/DO have documented participation in the visit. Participation in the visit requires more than a “hello” or a note saying that the MD/DO reviewed the plan of care and agreed to it, without contact with the patient.
• A service is provided solely by the APP that follows a plan of care previously established by an MD/DO during a previous encounter with the patient. The plan of care for the patient must be established during a visit in which the physician has direct patient contact and clearly documents a plan of care for the problem. This does not mean that on each occasion of an “incident to” service performed by an APP that the patient must also see the physician. It does mean there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the services being performed by the APP is an incidental part.

Next: Visits that cannot be billed incident toVisits that cannot be billed incident to:

• APPs cannot see new patients or established patients with a new problem and bill “incident to.” (Those visits should be charged using the APP’s NPI.)
• Most carriers have interpreted the combination of these guidelines to mean that any change in treatment plan not initiated during a visit in which the physician is an integral part of the service (direct contact required), or outlined by the physician in a documented care plan, that visit and any subsequent visit for the care are no longer eligible for “incident to” billing.
• A service cannot be charged “incident to” in the hospital. A service that is provided in a facility setting at the same times or at separate times by both an APP and an MD/DO cannot be reported under “incident to” rules. However, a visit in which both an APP and a DO/MD have contact with the patient and each documents that services including HX, PE, and MDM were provided can be reported under the MD/DO provider number under the Shared/Split visit rule, which allows for all services provided by both providers to be reported under a single E/M code by the MD/DO. Please note that documentation that simply indicates that the MD/DO has reviewed the documentation of the APP and agrees is not sufficient to meet the requirements of a Split/Shared Visit.

Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at UT@advanstar.com. Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.