E/M Coding Alert - 2015 Issue 8
Incident To: Appropriate Incident-To Billing Requires Keen Understanding of 'New Medical Condition
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Article Overview
This article discusses incident-to billing under Medicare, focusing on how practices should think about new versus established medical issues when non-physician practitioners provide follow-up care. It is aimed at billers, coders, compliance staff, and practice managers who need to understand how CMS guidance, payer differences, and state scope-of-practice considerations affect whether an encounter can be billed under a physician’s NPI or under the NPP’s own NPI. The discussion covers broad categories of conditions, the role of physician-established care plans, and the general circumstances that affect incident-to applicability.
Why This Topic Matters
Incident-to billing can affect payment level, compliance risk, and documentation expectations for visits performed by NPPs. Understanding how CMS guidance is applied helps practices avoid billing errors and better align workflows with payer requirements.
Article Sections
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Start with the Basics
Introduces the CMS incident-to framework and the role of NPPs in established care plans. It also frames the payment and coverage context for new versus follow-up visits.
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Payer differences
Notes that incident-to billing is a Medicare concept and that other payers may handle the same scenario differently. The section emphasizes the need to confirm payer-specific policy.
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Examine “Condition” vs. “Problem”
Discusses terminology used in the guidance and whether different labels change the general incident-to analysis. It focuses on how the article interprets the relationship between these terms.
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Define ‘New’ Problem
Addresses broad categories of patient issues, including chronic, acute, and recurrent situations. The section explains how these categories are discussed in relation to incident-to billing and physician-established plans of care.
What You Will Learn
- How incident-to billing is framed in Medicare guidance
- Why payer policy differences matter for NPP services
- How the article distinguishes broad categories of patient issues for incident-to analysis
- What role an established physician care plan plays in follow-up billing
- How state scope of practice can affect billing under an NPP’s own NPI
Who Should Read This
- Medical coders
- Billing staff
- Practice managers
- Compliance professionals
- Physician practices using NPPs
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