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Incident-to Coding: Physician vs. Non-physician Provider

Incident-to Coding: Physician vs. Non-physician Provider

Question: Our practice needs to make sure that “incident-to” guidelines are being followed.

Part of the Medicare guidelines is that the physician must stay involved in the patient’s care, but they don’t give a specific timeframe. If the patient only sees the non-physician provider (NPP) once or twice a year, and only sees the physician every two to three years, would Medicare consider that as the provider staying involved in the patient’s care?

Answer: Once upon a time, Medicare had an “every third or fourth visit” to see the physician guideline. They removed it over a decade ago, and didn't replace it with anything specific.

The most current language is that the physician must be “actively involved” and the services provided incidental-to the physician’s overall management of the patient be ”an integral part of the patient’s treatment course.”

So with no specific criteria, this becomes more difficult to measure with certainty. 

I would look to the physician’s last visit for each NPP chart you review, and see what the “plan of care” looks like. Then see if the NPP is operating within it, related to it, or perhaps even outside of it.

This is the most difficult aspect of “incident-to” to assess. It is easier to measure physician presence, and new versus established problems.


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