Incident-To Billing When the Nurse Practitioner Changes the Plan
A 70-year-old established patient with COPD is seen in a primary care clinic by a nurse practitioner (NP). Four weeks earlier the physician documented: 'Continue tiotropium; recheck in three months; call if dyspnea worsens.' Today the patient reports two days of increased dyspnea and a productive cough. The NP orders prednisone and levofloxacin, changes the inhaler to a combination agent, and documents a 20-minute visit with moderate MDM. The physician is in the building seeing other patients but does not see this patient. The NP is licensed and credentialed with Medicare. The coder submits the claim under the physician's NPI at 100% of the Medicare fee schedule, using the physician as the billing provider. The clinic's manager asks whether incident-to billing is supportable. The patient has been seen in the practice for six years.
1. Is incident-to billing supportable? Why or why not?
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No. Medicare incident-to billing requires that the physician establish the plan of care, that the patient be established, that the service be an integral part of the physician's course of treatment, and that the physician provide direct supervision. The NP did not merely carry out the physician's plan. The patient had a new or worsening problem, and the NP independently added antibiotics, prednisone, and a new inhaler. That is an independent NP service, not an incidental part of the physician's plan.
The fact that the physician was in the building is not enough. Direct supervision requires the physician to be immediately available, but it does not authorize the NP to change the plan and still bill under the physician. The service should be billed under the NP's NPI at 85% of the Medicare fee schedule, assuming the NP is enrolled and the payer permits NP billing.
2. How should the claim be corrected, and what are the reimbursement implications?
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The claim should be corrected to show the NP as the billing and rendering provider, with the appropriate place-of-service and diagnosis codes. If the claim was already submitted under the physician, the practice should submit a corrected claim or void and rebill, following the payer's rules. The reimbursement will generally be 85% of the Medicare physician fee schedule for the NP service, rather than 100% under the physician.
The practice should also review whether the physician could have personally seen the patient. If the physician had examined the patient and documented the plan, the service could be billed under the physician at 100%. The manager should compare the documentation with the incident-to requirements rather than assuming that physical presence in the building is sufficient.
3. What supervision and patient-status requirements apply to incident-to?
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For Medicare incident-to, the patient must be established, the physician must have established the plan of care, and the physician must provide direct supervision, meaning the physician is in the office suite and immediately available. The service must be an integral part of the physician's course of treatment. A new patient cannot be billed incident-to; the patient must have an established relationship with the practice.
State scope-of-practice rules and payer contracts may impose additional requirements. Some commercial payers do not recognize incident-to at all. The practice should verify the NP's credentialing, collaboration agreement, and payer enrollment before submitting the claim under either provider.