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Healthcare Practice Strategies - Spring 2015 - Questions and Answers: How to Avoid Incident-to Overbilling

May 13, 2015

The Office of Inspector General is keeping a close eye on "incident-to" billings to ensure they are appropriate. Consider the answers to these common questions to ensure proper compliance and appropriate reimbursement:

Can a new patient visit be billed as "incident to" when handled by an NPP?


A: No. For services to be considered incident to, there first must have been a "direct, personal and professional service furnished by the physician to initiate the course of treatment," according to Medicare regulations. Care provided to a new patient or an established patient with a new health care problem may never be billed as incident-to a physician service. To bill for the NPP, the physician must have seen the patient first at a previous encounter and established the plan of care.

If the doctor is on his way in, does that count toward supervision requirements?


A: No. For follow-up services to be billed as incident to, they must be furnished by an employee or independent contractor under immediate personal supervision of a physician. Therefore, an incident-to bill is not permitted for visits occurring while the physician is out of the office for lunch or on other business.

Is it more efficient and profitable to have the NPP see patients in the office or the hospital?


A: The regulations state that NPPs can bill incident to for services that are normally furnished in a physician's offices. Therefore, if NPPs perform rounds in the hospital for the physician or visit a skilled nursing facility to see the physician's patients, they must bill under their own provider number.

What is the difference between incident to and shared visits?


A: In general, incident-to services are for office-based services, and shared visits are for hospital services. Specifically, shared services are E/M services that a physician and an NPP provide jointly and are reported in the emergency department, outpatient department or inpatient department of the hospital. Both the physician and the NPP must provide a face-to-face service to the patient on the same calendar day and both must document their portion of the work. The combined work is then billed under the physician's provider number for 100 percent of the Medicare physician fee schedule — even if the NPP performed the majority of the work.

The difference in reimbursement between incident-to (100 percent) billing and billing under an NPP's own provider number (85 percent) can be substantial. So make sure you follow the rules.

Healthcare Practice Strategies - Spring 2015

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