SHARED VISITS AND THE "INCIDENT TO PROVISION" STILL AN ISSUE
Q: We are a group practice that uses non-physician providers such as physician assistants and nurse practitioners. We still are unclear pertaining to appropriate billing of spilt/shared visits between a physician and non-physician practitioner. Using Medicare guidelines can you define a split/shared visit and provide an example?
Administrator, Medical Practice
Broward County, FL
A: According to Medicare guidelines, a spilt/shared visit is a medically necessary encounter with a patient where the physician and qualified non-physician practitioner such as a physician assistant or nurse practitioner each performs a substantive portion of the evaluation and management visit, face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, examination, and medical decision making components of the E/M service. Simply signing off on the non-physician provider's note does not meet the criteria for a spilt/shared visit.
An example of a spilt/shared visit is a hospital inpatient E/M service that is shared between the physician and non-physician provider. In this scenario the non-physician provider and the physician both provide components face-to-face of the E/M encounter with the patient at separate times during the day. This service may be billed under the physician or the non-physician provider's National Provider Identifier (NPI).
Q: I understand that direct supervision is required to comply with "Incident-to" provision". If a physician is in the suite, can an initial/new patient visit be billed under the physicians NPI when the service is completely provided by a nurse practitioner?
Fort Lauderdale, FL
A: The main requirements for a provider to bill "Incident-to" are as follows:
·The services are an integral, although incidental, part of the physician's professional service;
·The service is commonly rendered without charge or included in the physician's bill;
·the service is furnished in the physician's office under the physician's direct supervision;
In order for the service to qualify as "incident-to", an initial office visit must have occurred between the physician and the patient, and a course of treatment is established by the doctor. In the initial office visit you describe, the services are performed by the non-physician provider and do not meet the "incident-to" requirements although you are available in the suite. You never saw the patient and therefore cannot have a plan of treatment. Therefore, the non-physician provider would need to bill this initial encounter under their NPI number.
Q: I employ two nurse practitioners and provide nursing home visits throughout Palm Beach County. Can the nursing home visits provided by nurse practitioners be billed as "incident-to", a supervising physician as long as the physician is also in the facility seeing patients?
Palm Beach, FL
A: The "incident-to" provision does not apply to institutional settings such as hospitals and nursinghomes. It is possible in the hospital setting for the physician and nurse practitioner to provide a shared/ spilt visit and bill it under the physicians NPI number if all the guidelines are met. Shared visits rendered in the nursing home cannot be billed to Medicare. The only exception to this is when the physician is renting space from the nursing home and has his/her own office within the facility. In this scenario; the office space must be confided to a separately identifiable part of the facility. Your staff may provide services in the office to out-patients and meet all of the components of the "incident-to" provision including direct supervision in order to bill under your NPI. In the event that your non-physician provider employee provides these services outside of the office area, these services would not qualify as "incident-to"
Q: Last week, a patient of mine was diagnosed with hypertension and placed on a regiment of medication and diet. I also wrote in my plan of treatment that the patient should be seen times-three (x3) in the office by my physician assistant to access the patient's progress. I understand that if I am available and provide direct supervision, that this service can be billed under my NPI. If I am not in the office when the service occurs but my partner is in the office, is the physician assistant visit eligible for "incident-to" billing?
A: Yes, the physician assistant visit is eligible for "incident to" billing. According to Medicare's guidelines, direct physician supervision in a clinic or office may be the responsibility of several physicians, as opposed to an individual attending physician. The physician who initiates the course of treatment doesn't need to be the same physician who oversees the physician assistant performing an incidental service. The service you described may be billed under your partner's NPI who is physically in the office suite and providing direct supervision at the time of the service.
Benjamin L. Frosch, is the President of Frosch Medical Consultants, Inc. in Plantation, FL