Confused about incident-to physician coding and billing compliance?

October 2nd, 2017 / By Barbara Aubry, RN

I recently attended a presentation hosted by my local HFMA chapter. It was an excellent discussion regarding the ins and outs of compliant coding and billing for incident-to services by Advanced Practice Clinicians (APC). Professionals in this category may also be known as non-physician extenders (NPP), limited license practitioners (LLP) and advanced practice providers (APP).

I was reminded of the challenges I have faced and thought I would share them in today’s blog—considering the increased use of APCs in the myriad pay-for-performance models. Incident-to coding and billing accuracy is important—the services are reimbursed at 85 percent of the physician’s fee schedule allowance—and complicated by a myriad of rules.

Nuts and Bolts

So, who exactly can bill as an APC incident-to a physicians service? The following folks:

  • Physician Assistants
  • Certified Registered Nurses (Midwives, Anesthetists)
  • Nurse Practitioners (unless they have their own NPI)
  • Advanced Practice Registered Nurse
  • Physical and Occupational Therapists
  • Clinical Psychologists, Social Workers and Nurse Specialists

What, exactly is an “incident-to” service? According to CMS Pub. 100-02, Chapter 15, Section 60.1: 

“Incident to a physician’s professional services means the services are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis of an injury or illness. It is permissible to bill under a physician’s name when services provided by an APN/PA are “incident to” a physician’s established plan of care”

CMS has rules that govern provision of incident-to services in multiple sites; this blog focuses on those provided in the physician’s office. An important component of the incident-to rule is the specific requirements for physician supervision (of advanced practice clinicians providing services). For services provided in the physician office, CMS requires “direct supervision.” Specifically:

“To qualify as incident-to, services must be part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment. You do not have to be physically present in the patient’s treatment room while these services are provided, but you must provide direct supervision; that is, you must be present in the office suite to render assistance, if necessary”.(Bold provided by CMS)

Guidelines

Provision of incident-to services requires specific compliance. More on who, what and where:

  1. Incident-to services can only be provided in the office setting for established patients who have been seen previously by the physician.
  2. There must be a documented and clearly defined plan of care established by the physician and accessible by the APC at the time of the visit.
  3. The physician providing direct supervision is considered a billing provider on a specific date of service and does not need to be the same physician who created the plan of care.
  4. Solo physician practitioners must be present in the office as supervisors.
  5. In a group practice, any member of the group can be present to supervise care.
  6. The service provided must be within the scope of practice of the APC.
  7. Incident-to services do not include provision of flu shots, EKGs, laboratory tests (excluding anti-coagulation monitoring) or x-rays performed in an office setting.

Documentation

According to CMS, the patient record must document the essential requirements for incident-to services. Specifically, the services must be all of the following:

  • “An integral part of the patient’s” treatment course
  • Commonly rendered without charge (included in your physician’s bills)
  • Of a type commonly furnished in a physician’s office or clinic (not in an institutional setting)
  • An expense to you (caregiver whom you directly supervise and who represents a direct financial expense to the practice)”

In addition, the overarching idea of documentation of the medical appropriateness of services also applies. Ideally, the supervising physician should be of the same specialty as the physician providing the initial examination and plan of care. CMS requires that the physician must be actively involved in the on-going care. Usually, the physician would see the patient every third visit or yearly, whichever is sooner.

Carriers may deny any incident-to services that do not contain documentation of the initial patient visit and care plan created by the physician. This must include the history and physical examination and creation of an on-going treatment plan. Incident-to claims will be denied when a non-physician practitioner performs the initial history and exam.

When a new problem arises during an incident-to visit, the APC should collaborate with the supervising physician. This should be documented in the patient record including any modifications to the plan of care. In this instance, the physician must sign the record.

A physician co-signature is not required for “routine” incident-to visits but it is suggested since it shows the physician’s continued involvement in the plan of care. A co-signature by the physician alone is insufficient to support incident-to; all above documentation criteria must be met.

The documentation must clearly reveal the name and credentials of the individual providing services on any given date. This should include documentation of the supervising physician’s availability in the office. When requirements are met, the incident-to encounter can be billed under the name of the supervising physician.

Services that do not qualify for incident-to:

  1. Any services that can be provided without a physician’s supervision cannot be billed as incident-to; think laboratory services (except those such as coagulation monitoring which requires visits for medication management), flu shots, EKG, certain radiology services, etc.
  2. New patient office visits (CPT 99201-99205)
  3. Office consultations (CPT 99241-99245)
  4. Preventive examinations and yearly physical exams including Medicare IPPE, AWV, etc (CPT 99381-99387, 99391-99397)
  5. Any new problems encountered during the visit that are not addressed in the established plan of care. In this instance, the supervising physician needs to see the patient
  6. No services can be billed incident-to when the supervising physician is not present in the office

Because incident-to services are audited and the rules are complicated, coders need to be aware of the requirements. There is some confusion between incident-to and “shared visit” which is actually different – but that’s a topic for another blog.

Barbara Aubry is a regulatory analyst for 3M Health Information Systems.