August 5, 2022 | By Michele Strickland, CPC, CEMA
Incident-To is often discussed in coding and compliance circles, but when reviewing encounters, I routinely find the criteria fails to meet or support the billing of non-physician practitioners (NPPs) and/or other clinical staff (auxiliary).
There are two types of Incident-To services; a component of the service is being performed by a clinical staff member of the physician or non-physician practitioner (NPP), and a service being performed by a non-physician practitioner (NPP) as an integral part of a physician’s course of treatment for the patient. This audit tip will focus on services performed by NPPs.
Direct supervision is required by the physician but does not mean they need to be present in the room during treatment. To report direct supervision, the physician must be in the office suite and immediately available (this term is not clearly defined by CMS; however, it should be within seconds of an incident and/or the need for physician skills) to assist/ take over or direct throughout the visit. When the physician is not on site while the NPP renders services, they are no longer considered or supported as Incident-To. When this occurs, the NPP must bill the services under their National Provider Identifier (NPI).
Another requirement is active involvement from the physician after that initial service is performed. CMS does not give specific details on the timing of follow-up visits. However, the frequency must be able to demonstrate that the provider has been engaged in the ongoing care of that patient. This is an area of opportunity for creating an internal policy to ensure that after ’X’ number of visits, the physician engages with the patient independently.
When auditing services billed as Incident-To, look beyond the current note being audited to ensure these requirements are being met. In addition to the CPT codes and diagnosis codes being supported, determine if the following factors are documented in the chart to support billing Incident-To:
- New vs. Established Patient– New patient encounters cannot be billed Incident-To as the physician did not perform the service to initiate the plan of care. For established patients, it’s important to review the chart to ensure the physician performed the initial service where the plan of care was initiated. In a past audit review, it was discovered that the patient’s encounters performed by an NPP were billed Incident-To, and the patient had never been seen by the physician.
- Existing Conditions– Are the conditions being managed on this date established with no changes to the treatment plan that was created by the physician? If the patient is being seen for an existing condition where a change to the treatment plan initiated by a physician is required, the service no longer meets the definition of Incident-To and must be billed under the NPP’s NPI number.
- Established Patient With a New Problem– An established patient seen by an NPP with a new problem where a new course of treatment is initiated does not meet the requirements of Incident-To and must be billed under the NPP’s NPI number. This is one of the top scenarios where Incident-To is not supported.
- Active Involvement– While this is a gray area open to interpretation, it’s important to determine if the chart shows active involvement by the physician that makes sense for the conditions being managed. If the chart shows it has been 2 years since the patient was last seen by the physician, can we really justify active involvement?
While billing Incident-To Services can mean a slight increase in revenue, it can also quickly result in improper payments for services rendered. It’s important to regularly review guidelines to ensure we continue to remain compliant. Incident-To does not automatically apply to all patient encounters. Review your local Medicare carrier policy and consider an internal policy to help keep your practice compliant.
Reference: Medicare Benefit Policy Manual Chapter 15 section 60