Novitas Solutions
Medical Review (MR) Department has observed a continued trend of the
utilization of non-physician practitioners to perform initial office visits as
"incident to" services. Documentation reviewed by the MR Department
indicates that a non-physician practitioner performs the initial visit and the
supervising physician documents a note in the medical record similar to the
following:
"I have reviewed the Physician Assistant's note, examined the patient and
agree with..."
“Nurse practitioner performed the history and physical and I was present for
the entire encounter and my treatment plan is as follows……”
This is incorrect use of the non-physician practitioner and incorrect billing
under the "incident to" guidelines. This article explains the
Medicare definition of "incident to" services and the criteria that
must be met to properly bill "incident to" services.
An initial history and physical performed by a non-physician practitioner,
although the physician is documented as being present or in the office suite
and immediately available, is not covered under the "incident to"
guidelines. As outlined below, the physician MUST perform the initial service.
This includes the history and physical, examination portion of the service, and
the treatment plan. It is expected that the physician will perform the initial
visit on each new patient to establish the physician-patient relationship.
Novitas Solutions MR will deny or down code claims for initial office visits
billed as "incident to" when a non-physician practitioner performs
the initial history and physical .
CMS defines "incident to" services as “services or supplies furnished
as an integral, although incidental, part of the physician’s personal
professional services in the course of diagnosis or treatment of an injury or
illness.”
In order to be covered as "incident to" the physician’s service, the
following criteria must be met:
services must be an integral, although incidental, part of the physician’s
professional service, commonly rendered without charge or included in the physician’s bill,
of a type that are commonly furnished in physician’s offices or clinics, and
furnished by the physician or by auxiliary personnel under the physician’s
direct supervision
