A 67-year-old patient with diabetes shows up for her appointment. Her A1C levels are high. She reveals during the visit with the advanced practice clinician that she’s not taking her medication as prescribed. The patient’s physician is doing rounds at the hospital and is, thus, unavailable to consult with the patient in person.
At this point, the practice needs to answer a couple questions:
- Can the nurse practitioner (NP) or physician assistant (PA) bill the visit under his/her own national provider identification (NPI) number?
- Or, is the visit appropriate for “incident to” billing and, thus, billable under the physician who created the patient’s care plan?
It depends, says Kim Huey, CPC, president of Birmingham, Ala.-based KGG Coding and Reimbursement Consulting, which helps physician practices improve coding and documentation of service as well as ensure compliance with Medicare and insurance company regulations.
If the physician only recommended metformin in the care plan, and that medication hasn’t been used by the patient, the advanced practice clinician needs to create a new plan of care or bring another physician into the patient’s room to develop a plan of care, Huey says. In the first scenario, the practice can bill Medicare 85 percent for the visit because it’s billed under the advanced practice clinician, whereas in the second, Medicare is billed 100 percent because the newly-introduced physician developed the plan of care upon conducting a visit with the patient.
However, if the physician who created the initial care plan included a variety of options, such as different medications to treat the patient’s diabetes, the advanced practice clinician can choose from one of the provided options and still bill the encounter as “incident to.” And that means the practice can bill the encounter at 100 percent of the physician’s rate, Huey says.
Practices around the country struggle to learn and apply the nuances of “incident to” billing—in addition to keeping tabs on the documentation needs of various private payers regarding advanced practice clinicians. Here are five things practices need to keep in mind regarding coding and billing for physicians and nonphysicians on their clinical team.
Understand “incident to” billing
CMS defines “incident to” billing as “services that are furnished incident to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home.” To qualify as “incident to,” services must be part of the patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the patient’s care.
The physician doesn’t have to be in the exam room while services are provided during subsequent visits, but the physician must provide direct supervision. That means the physician must be in the office suite for clinical decision-making should the care plan change. CMS also requires the patient record includes documentation of essential requirements for “incident to” service.
Practices should exercise caution in the way they structure and document patient visits if they want to bill encounters as “incident to” the initial physician’s plan of care.
Specifically, this means the physician must conduct the entire new patient visit; however, another clinician can conduct a review of systems with the patient. If, for example, a patient with hypertension returns to the practice—after an initial visit with the physician—and sees the NP, that encounter can be billed under the physician.
Huey, who conducts insurance compliance audits at physician practices, says NPs and PAs should document in the EHR they’re providing care to the patient that follows the physician’s care plan.
If they don’t, there can be consequences. She’s working with a practice that’s settling with the U.S. attorney’s office on a billing-related issue. The problem? It wasn’t clear from patient records that the NP had even consulted the physician’s care plan during the patient visit.