Blanket 'Incident-To' Billing for NP Visits
A Medicare patient established to a five-physician primary care practice is seen by a nurse practitioner for a new complaint of intermittent dizziness with one near-syncope episode. The NP takes the history, examines the patient, orders an ECG and labs, and starts a workup; the medical decision making supports 99214. The supervising physician is in the building seeing another patient, does not enter the room, and does not review or discuss the case that day. He co-signs the NP's note three days later. The practice's written policy is to bill every NP encounter under the physician's NPI as 'incident-to' because the physician is always on site during clinic hours. The biller has already submitted 99214 under the physician's NPI.
1. Was the claim correctly billed as incident-to? Walk through the requirements.
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No. Incident-to billing requires all of the following, and this encounter fails at least two of them:
- The service must be part of the physician's established plan of care for an established problem - here the dizziness is a new complaint with a new workup, so there is no pre-existing physician plan to be 'incident to.'
- The physician must have initiated the course of treatment for the condition.
- The physician must be physically present in the office suite and immediately available - that element is arguably met (same building, seeing another patient), but presence alone does not create incident-to status.
- The service must be an integral, incidental part of the physician's service, not a service that would ordinarily be billed separately.
Correct billing: report 99214 under the NP's own NPI, paid at 85% of the Medicare fee schedule, with the NP as rendering provider. The physician's three-day-later co-signature does not retroactively convert the service, and co-signing a note the physician did not author does not establish that he performed or supervised the service.
2. The physician says, 'I looked in on the patient for five minutes and agreed with the plan - can I just bill it under me?'
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Not on these facts. Two separate issues:
- Split/shared visits (where a physician and NPP each perform part of a single E/M in a facility setting and the practitioner who performs the substantive portion bills) apply to facility settings for Medicare. This is a physician office - a non-facility setting - so the split/shared construct does not rescue the claim. The choice remains: incident-to (requirements not met) or bill under the NP.
- A brief physician add-on visit cannot be carved out and billed as its own E/M unless it is separately documented as a distinct, medically necessary service. A five-minute 'agree with plan' entry does not constitute a separately identifiable E/M, and appending modifier 25 to manufacture one is exactly the pattern auditors look for.
Also note the direction of the error: the physician's NPI was used for work the NP performed, which overpaid the claim at 100% instead of 85% and misidentified the rendering provider - a false-claim issue, not a clerical one.
3. What corrective action does the practice owe now, and what should happen to the policy?
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The submitted claim is an overpayment and must be handled through compliance process, not left for the payer to find:
- Stop the practice. Suspend blanket incident-to billing and add a hard stop in the charge scrubber: NP-performing claims default to the NP's NPI unless a coder affirmatively documents the incident-to elements.
- Scope the exposure. Run a retrospective audit of NP claims billed under physician NPIs - a statistically valid random sample per provider, scored against incident-to criteria (established problem, physician-authored plan, physician on site). Extrapolate to estimate the population but compute the refund on actual identified claims.
- Refund. Report and return the identified overpayments within 60 days of identification; if the pattern is systemic, evaluate self-disclosure.
- Fix the policy. Rewrite it to reflect that on-site presence is necessary but not sufficient, and that new problems, new patients, and services that would ordinarily be billed separately fall outside incident-to.
- Educate the NPs, the physicians who co-sign, and the front-desk staff who capture charges; re-audit in 90 days.