• Benign Prostatic Hyperplasia
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'Incident to' billing rules open to interpretation


The issues are too complex for a simple answer when it comes to 'incident to' billing.

Q: I am really struggling with having my physicians understand the "incident to" rules. I cannot get them to understand that they need to have initially seen the patient for the problem the nurse is billing as "incident to." The most common example: A patient comes in with urinary tract infection symptoms to see the nurse only. The physician feels that since he is on site and the nurse relays the patient's problems to him, we can bill a nurse visit (99211), even though the patient was never seen by a physician for an initial evaluation and treatment plan for this problem. It's my understanding that the patient needs to have seen the physician first. Is that correct?

To start, the qualifying rules that you refer to pertain to a non-physician provider. The Medicare Carriers Manual, referring to "incident to billing" for an NPP (physician assistant or nurse practitioner), specifically states: "There must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the non-physician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physician's continuing active participation in and management of the course of treatment." There is no similar statement referring to other office personnel providing a level one established patient code.

There are no additional clarifications that we can find, leaving a lot open to interpretation. One could surmise that the intent of the Centers for Medicare & Medicaid Services for the NPP would be the same for all employees. Or, one could surmise that the protocols set up by the physician and the personal involvement in the decision making (review of recommendation with the nurse) related to the UTI and prescribed treatment are "an integral, although incidental part of the physician's professional service." As these regulations are less than precise, the billing physician is left to decide where to draw the line.

The dilemma of a new patient

If the patient is new to the practice, the dilemma is even greater. The encounter does not qualify for a new patient code, yet the patient is not an established patient. The question would be whether Medicare's rule indicating, "You are required to charge for all services provided" would override the Current Procedural Terminology definition of an established patient encounter. If the answer is no, it would have to be considered a non-covered event and, therefore, potentially billable to the patient.

(We are not recommending that you charge the patient unless you have a ruling from Medicare in writing.)

Another alternative: Delegation

Another option is to have the office personnel, nurses, medical assistants, etc. take a complete history and physical examination. Following this, have the physician briefly see the patient and charge a new patient visit. According to your scenario, the physician had already been presented with the problem and established a treatment plan. Therefore, this could be accomplished without the urologist having to spend a significant amount of extra time. Delegation is the key and is acceptable, according to the rules.

Disclaimer: The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook. Mark Painter is CEO of PRS Urology SC in Denver.

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