Exam Coding

The code (99213 or 99214) doesn't really matter but the modifier for "incident to" matters a lot.

From the ACNP website:

What is "incident to billing"?

Q. What is "incident to billing"?

A. "Incident to" billing is a Medicare term which can be applied to patients being billed under the fee for service system with Medicare. Medicare's "incident to" billing has specific requirements which must be met to bill physician services "incident to" a physician.

Medicare Regulations at 42 C.F.R. Section 410.26 provide that Medicare Part B will pay for services and supplies incident to a physician's professional services, including drugs and biologicals that cannot be self-administered, as long as the services or supplies are of the type that are commonly furnished in a physician's office or clinic, and are commonly furnished either without charge or are included in the physician's bill.

The Medicare Carrier's Manual list the criteria are for a service to qualify as "incident to" the services of a physician. To quality for reimbursement, the service must be an integral part of the physician's professional service, commonly provided without charge or included in the physician's bill; commonly furnished in physician offices; and furnished by the physician or by an individual who qualifies as an employee of the physician.

A physician can bill for the services of a nurse practitioner if the nurse practitioner's services are billed incident to the physician's services; however to do so, the physician must meet certain supervision requirements. The services must be performed under the direct personal supervision of the physician as an integral part of the physician's personal in-office service. Such direct personal supervision requires that the physician initiate the course of treatment for which the service being performed by the nurse practitioner is an incidental part and that the physician remain actively involved with the patient's care. The physician must also be physically present in the same office suite and be immediately available to render assistance if necessary. In addition, the nurse practitioner must be employed by the physician (or be a leased employee). Services provided by auxiliary personnel not in the employ of the physician, even if included in the physician's bill, are not covered as incident to a physician's service.

The advantage of billing "incident to" is the practice receives 100% of the physician fee schedule for the service. The disadvantage is all of the incident to requirements must be followed. If a nurse practitioner bills directly for his or her services under their own Medicare provider ID number, the nurse practitioner receives 85% of the physician fee schedule. The advantage is that the restrictive "incident to" rules do not apply for nurse practitioners billing directly under their own number. Incident to billing is not permitted in hospitals, skilled nursing facilities or in the home.

"Incident to" is very restrictive and basically applies only to very particular scenarios. Such as:

The physician sees a new patient and diagnoses hypertension, obesity, and tobacco abuse. The patient is scheduled to return in two weeks to see the NP ONLY regarding those three, already-established diagnoses AND must provide services that would normally be "without charge or included in the physician's bill." So essentially you could weigh the patient, check his/her blood pressure, and ask them where they are in the smoking cessation process. If the patient also has a twisted ankle on the day of that visit with the NP, it cannot be addressed under "incident to."

Another possible scenario for "incident to" would include a patient who had a laceration repair by the physician. The pt returns in 7 days for evaluation of readiness for suture removal. The NP can do that and bill it under the physician's name/number as "incident to."

Lots of great information. Thanks so much. Being a new NP, I want to protect myself. This doc has already done many shady things that make me very apprehensive. I appreciate you all for taking the time to answer my question and give me a resource so that I can present this to her.