Many of you over the years have asked me about the rules regarding “incident-to” when it comes to nurse practitioners. We just shipped our latest Medical Office Strategies subscription and one of the chapters deals with this topic. Let me sum it up for you in the next few paragraphs:
Incident-to is a Medicare term (although in some states Medicaid may use it also). Most private insurers do not use this term. Medicare applies this term when the NP is billing under the physician’s number instead of the NP’s number. By doing so, collections will be at the 100% physician rate instead of the 85% NP rate.
To bill incident-to, this cannot be a new problems or a new patient. The NP must be seeing the patient for an established problem. In order to get the best bang for your “NP/Medicare” buck, that means schedule follow-ups with the NP and have the physician see acute or new issues or patients.
The supervising physician must be in the same clinic space as the NP in order to bill incident-to. They cannot be “available by phone” or even in a different clinic in the same building. If you are not in the same “practice location” at the same time, you have to bill at the 85% NP rate.
Incident-to rules do not apply to inpatient, nursing home, or anything other than outpatient services. For any other service, the NP would bill under their own number, or the physician would be required to see the patient and write the notes. I’ve actually seen NPs used extensively in hospitals to save the physician time. The NP will see the patients and write the notes and orders. The physician would then follow and write any additional items and also see the patients. It is not really “double-work” since it saves quite a bit of time for the physician so more patients can be seen.
In actual terms this means the NP cannot become their primary care provider seeing them for the next 5 years without the physician. The accepted rule is that the physician must see the patient at least 1 out of 4 times. As a general rule, that means when the NP schedules a follow-up visit, he needs to look and see how long it has been since the physician was seen. If it’s been 3 times, then the next visit needs to be scheduled with the doctor.
Nurse Practitioners have the option of billing under their own number with Medicare for 85% rate. PAs cannot do this. When billing Medicare they must bill under the doctor’s number and follow all of the above rules.
Even if the NP is only working in the same clinic at the same time as the doctor, and never bills under her own number, she must still be credentialed with Medicare as a provider for that clinic/billing entity. They still have to know who is seeing their patients in a particular clinic.