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


In this month's coding column, we also feature answers to prolonged services codes and orthopedic ICD-10 codes.

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.

Question:  Since prolonged services codes remain on the Office of the Inspector General’s watchlist, I want to clarify something about extended visits and documentation. I recently conducted a visit and easily met criteria for a 99213 managing hypertension, depression follow-up with medication, and an abnormal mammogram, then did separate obesity counseling for 31 minutes.  My documentation included the line:

After our visit for hypertension, depression, and abnormal mammogram findings we spent 31 minutes discussing her battle with chronic obesity including various diets, exercise, medications, and developing a plan.

I know if I’m doing extended visits, it is based on time for both components of the visit. Is the note above sufficient in addition to some history and exam?

Answer: The note you wrote has the right idea. You create some separation in the services. But I might amend it as follows:

In addition to the chronic disease follow up visit today for the patient's hypertension, depression, and abnormal mammogram documented above, we spent an additional 31 minutes of prolonged services discussing her battle with chronic obesity including various diets, exercise, medications, and developing a plan.

This version identifies the chronic disease management portion, and then specifically identifies the prolonged portion of the visit as prolonged services. 

Question: I’m an internist and would like to know what ICD-10 codes I should use for taking care of someone in rehab status post L3-S1 laminectomy. Do I use the Z code for orthopedic after care? I only found codes for the type of approach during the surgery. I used the lumbar spinal stenosis which was the reason for surgery, but not sure about the rest.

Answer: Is it the orthopedic aftercare that you are being asked to manage, or the patient's other conditions while they are in rehab? If it is the broader co-morbid spectrum of issues, then code that or those first, including the stenosis (M48.06) and the Z code for aftercare (Z47.89). If it is only the ortho codes, then again, the stenosis followed by the aftercare code.

Facing a coding conundrum? We're here to help. Send your questions to coding expert Bill Dacey at He will help clear up the confusion, and you may even see your question featured online.

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