Before You Bill Incident To—Is the Treatment Plan Really There?
Scott Kraft, CPC, CPMA, CEMC, CPA-RA
Whenever you perform an audit under Medicare’s Incident to billing rules, you’re really auditing two different things. First, did the visit note support the code assigned and whether it included any documented changes to the patient’s treatment plan.
Second, you need to validate that the patient has a treatment plan in place created by a physician from the same group practice and same specialty at a previous office visit.
When the original treatment plan exists and the non-physician provider who saw the patient that day made no changes, then the visit can be supported under Medicare’s incident to billing rules.
As you know, Medicare’s incident to billing enables the non-physician provider to perform an E/M visit, but for it to be billed under a physician for 100 percent of the Medicare allowed fee, instead of the 85 percent of the allowed fee when the non-physician provider bills the service directly.
That extra 15 percent is not without its costs, however. Incident to billing has among the highest billing error rates on external review, and the HHS Office of Inspector General is currently undertaking a broad review of incident to billing that is expected to be released next year. If you’re doing incident to billing at your practice, odds are someone is watching – or will be.
The old auditor’s adage for incident to services remains true – no new patients, no new problems – but how the rendering physician sets up the plan of care may go a long way toward giving the practice the best chance to perform and document incident to services correctly and keep the extra 15 percent.
Here are some ways to educate physicians about the treatment plan:
- Document medications specifically. When the patient is on a medication, document the name of the medication and dosage information. This will make it easier to identify continuity of the plan when the medications are renewed.
- Document medication contingencies. In the original treatment plan, documentation can include contingencies such as a specific adjustment to a medication dosage if a lab value exceeds a level, or that a patient will switch from one medication to another if a medication doesn’t work.
- Clarify Orders when entered in the record. If the patient has orders for imaging or labs entered for specific intervals by the physician, make sure that is part of the treatment plan so the non-physician provider doesn’t need to document what appears to be a change in the treatment plan and lose credit for the incident to visit.
- Remain involved in the care. Even a well done treatment plan will get stale with age and increase the odds that a change will need to be made. CMS no longer allows an incident to visit in the office to be a split between two providers, so whenever the non-physician provider makes a change, it can’t be an incident to visit any longer. CMS requires the physician to remain involved in the care, so set a strategy to do so.
- Be ready to create a new plan. When the non-physician provider has changed the plan of care, make sure the next visit is with a physician to create a new plan.
It’s important to note that, even with the best laid plans, incident to billing gets sidetracked very easily. The provider can never know when the patient will either present with a new complaint or discuss a change to the status of an established condition. This would necessitate an unforeseen change to the treatment plan and block incident to billing.
The most critical staff members in your practice to understand this distinction are the non-physician providers, as they’re the only ones who will know when a visit intended as an incident to visit is sidetracked by a change to the plan.
These unforeseen variables will always play a role in the success rate of incident to billing. Creating detailed plans for each condition, including contingent changes and a clear status of the condition, gives you the best chance to be compliant at incident to billing. It’s also helpful to understand when a visit cannot be incident to and not to try to hard to make it happen when there are clear changes to the plan.
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Because when your plan is clear, your compliance is stronger.
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About Scott Kraft the Author
Scott Kraft is an auditor for DoctorsManagement. He also creates content for the firm’s educational division, the National Association of Medical Auditing Specialists (NAMAS).
Scott oversees the quality assurance process for client audits. He brings extensive experience in more than 30 specialties including but not limited to orthopedics, cardiology, vascular, neurology, obstetrics and gynecology, physical medicine and rehabilitation and physical and occupational therapy.
