“Incident to” and the Initial Visit – Evaluation & Management (E/M) Service Guidelines
Novitas Solutions Medical Review (MR) Department has observed a continued trend of the utilization of non-physician practitioners to perform initial office visits as “incident to” services. Documentation reviewed by the MR Department indicates that a non-physician practitioner performs the initial visit and the supervising physician documents a note in the medical record similar to the following:
“I have reviewed the Physician Assistant’s note, examined the patient and agree with…”
“Nurse practitioner performed the history and physical and I was present for the entire encounter and my treatment plan is as follows……”
This is incorrect use of the non-physician practitioner and incorrect billing under the “incident to” guidelines. This article explains the Medicare definition of “incident to” services and the criteria that must be met to properly bill “incident to” services.
An initial history and physical performed by a non-physician practitioner, although the physician is documented as being present or in the office suite and immediately available, is not covered under the “incident to” guidelines. As outlined below, the physician MUST perform the initial service. This includes the history and physical, examination portion of the service, and the treatment plan. It is expected that the physician will perform the initial visit on each new patient to establish the physician-patient relationship.
Novitas Solutions MR will deny or down code claims for initial office visits billed as “incident to” when a non-physician practitioner performs the initial history and physical .
CMS defines “incident to” services as “services or supplies furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.”
In order to be covered as “incident to” the physician’s service, the following criteria must be met:
services must be an integral, although incidental, part of the physician’s professional service,commonly rendered without charge or included in the physician’s bill,of a type that are commonly furnished in physician’s offices or clinics, and furnished by the physician or by auxiliary personnel under the physician’s direct supervision “Incident to” services must be performed under the direct supervision of the physician. CMS directs that “Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.”
CMS further indicates, under direct supervision, “This does not mean, however, that to be considered “incident to”, each occasion of service by auxiliary personnel (or the furnishing of a supply) need also always be the occasion of the actual rendition of a personal professional service by the physician. Such a service or supply could be considered to be “incident to” when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflects his/her active participation in and management of the course of treatment.” Hospital and skilled nursing facility services cannot be billed as “incident to” at any time.
Can ancillary staff that provides a service ‘incident to’ a physician or non-physician practitioner sign the documentation?
No. The physician or non-physician practitioner, who is responsible for the patient’s care, must sign the documentation. See our E/M Help Center article ‘Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices’ for more information.
Can incident to occur in place of service (POS) 19 or 22 (outpatient hospital)?
No. Incident to services are limited to the office setting (place of service (POS) 11). However, if a provider establishes an office in a larger outpatient setting, the ‘incident to’ services and requirements are confined to this discrete part of the facility designated as his/her office.
Hospital Based Physician (employees of the hospital)
The hospital is billing and ‘incident to’ does not apply
Submit POS 19 or 22
Group of physicians (not employees of the hospital) and the office is confined to the discrete part of the facility
The physicians are incurring the expense and ‘incident to’ would apply
Submit POS 11 (not POS 19 or 22)
Can the modifier that indicates ‘increased procedural services’ be submitted with an E/M service when a physician spends an extended amount of time with a patient?
No. CPT modifier 22 may only be submitted with services that have a zero, 10 or 90 day post-op period.
Based on E/M documentation guidelines, time is not a controlling factor in determining the level of E/M service unless more than 50 percent of the visit was spent counseling and/or coordinating care.
‘INCIDENT TO’ BILLING CLARIFICATION
Louisiana Medicaid issues the following clarification for billing services as ‘incident to’ a physician’s professional service.
• ‘Incident to’ a physician’s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness. This means that the physician, under whose provider number a service is billed, must perform or be involved with a portion of the service billed. Physician involvement may take the form of personal participation in the service or may consist of direct personal supervision coupled with review and approval of the service notes at a future point in time.
• Please note that direct personal supervision by the physician must be provided when the billed service is performed by auxiliary personnel. Direct personal supervision in an office means the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the service is performed.
• In addition to services performed by non-physicians, such as nurses or aides, services performed by other non-physicians whose licenses allow them to perform physician-type services (Nurse Practitioners, Physician Assistants, and others) may qualify as ‘Incident to’ a physician’s service. However, it is important to remember that, even if the physician supervision requirements are met, the service does not qualify as ‘Incident to’ unless the physician performs or is involved with some portion of the service billed.
• In situations where non-physicians such as an NP or PA provides all parts of the service independent of a supervising physician’s involvement, the service does not meet the requirements of ‘Incident to’ billing. Instead, the service must be billed using the provider number of the non-physician practitioner and must meet the specific coverage requirements of the practitioner’s scope of practice.