Carolyn Buppert, Law Office - Specialist in legal and reimbursement issues for nurse practitioners and physicians

Medicare requires that physician services billed to Part B Medicare be billed under the name and provider number of the individual performing the service, with exceptions. For example, when a nurse practitioner performs physician services for a patient covered by Medicare, those services must be billed under the nurse practitioner's provider number, and Medicare will pay 80% of 85% of the Physician Fee Schedule rate.

If the practice situation meets certain requirements, however, a nurse practitioner's services may be billed under a physician's provider number, and Medicare will pay 80% of the Fee Schedule rate. Medicare calls that situation "incident to" billing. Here are the circumstances under which a nurse practitioner's services may be billed incident to a physician's services, as specified in the Medicare Benefit Policy Manual, Chapter 15, Sections 60.1 to 60.3:

"In addition to coverage being available for the services of such auxiliary personnel as nurses, technicians, and therapists when furnished incident to the professional services of a physician, a physician may also have the services of certain nonphysician practitioners covered as services incident to a physician's professional services. These nonphysician practitioners, who are being licensed by the States under various programs to assist or act in the place of the physician, include, for example, certified nurse midwives, clinical psychologists, clinical social workers, physician assistants, nurse practitioners, and clinical nurse specialists.

Services performed by these nonphysician practitioners incident to a physician's professional services include not only services ordinarily rendered by a physician's office staff person (e.g., medical services such as taking blood pressures and temperatures, giving injections, and changing dressings) but also services ordinarily performed by the physician himself or herself such as minor surgery, setting casts or simple fractures, reading x-rays, and other activities that involve evaluation or treatment of a patient's condition.

Nonetheless, in order for services of a nonphysician practitioner to be covered as incident to the services of a physician, the services must meet all of the requirements for coverage specified in Sections through 60.1. For example, the services must be an integral, although incidental, part of the physician's personal professional services, and they must be performed under the physician's direct supervision. A nonphysician practitioner such as a physician assistant or a nurse practitioner may be licensed under State law to perform a specific medical procedure and may be able (see Section 190 or 200, respectively) to perform the procedure without physician supervision and have the service separately covered and paid for by Medicare as a physician assistant's or nurse practitioner's service. However, in order to have that same service covered as incident to the services of a physician, it must be performed under the direct supervision of the physician as an integral part of the physician's personal in-office service. As explained in Section 60.1, this does not mean that each occasion of an incidental service performed by a nonphysician practitioner must always be the occasion of a service actually rendered by the physician. It does mean that there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the nonphysician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects his or her continuing active participation in and management of the course of treatment. In addition, the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary. [Bolding provided by author.]

Note also that a physician might render a physician's service that can be covered even though another service furnished by a nonphysician practitioner as incident to the physician's service might not be covered. For example, an office visit during which the physician diagnoses a medical problem and established a course of treatment could be covered even if, during the same visit, a nonphysician practitioner performs a noncovered service such as an acupuncture."

Visit 1: Patient Zeller, a new patient covered by traditional Medicare, is evaluated by MD Oaks in July 2006 and diagnosed with high blood pressure. Dr. Oaks bills a level 3 office visit to Part B under his provider number. The full Physician Fee Schedule rate is applicable, which, in his case, is $94.26.

Visit 2: In October 2006, Patient Zeller is evaluated in follow-up of high blood pressure by NP Stone, an employee of Dr. Oaks. NP Stone codes a level 3 office visit, and Dr. Oaks bills the visit under his provider number. (Dr. Oaks was on-site when the NP conducted the visit.) The full physician rate is applicable, which is $51.68 in this case.

Visit 3: In January 2007, Patient Zeller arrives to see NP Stone for follow-up of high blood pressure. Patient Zeller states "I have another problem. My left ear hurts." NP Stone evaluates and manages both problems.

The dilemma: Whose provider number should Visit 3 be billed under -- Dr. Oak's or NP Stone's? Would the appropriate CPT code (assuming all other requirements are met) be a level 4, billed under Dr. Oaks ($81.06), a level 4 billed under NP Stone ($68.90), or a level 3 billed under Dr. Oaks ($51.68)? (Rates differ depending upon geographic area and specialty). Medicare regulations provide no answer to this question.

"Q: If a nurse practitioner sees an established patient for an established problem, and during the course of the visit diagnoses a new problem, how would the service be billed to Medicare?

A: It is my opinion that the service can be billed 'incident to.' The service initially, as scheduled, met the 'incident to' guidelines since the patient was seen for an established problem. The only caveat is that the services related to the new diagnoses should not be utilized when determining the level of care for an evaluation and management service. The rationale is that the physician must perform an initial service and subsequent services (for the new condition) of a frequency that reflected his/her active participation in and management of the course of treatment. Therefore, the initial service for the new condition cannot be considered when determining the level of care."

"Q: ...[W]hen the NP is talking to the patient during the exam the patient explains a new problem that has not been addressed before. Can the NP continue to perform the service and have it billed under 'incident to' guidelines?

A: In order for the service to be reported under the physician's provider number, the employing physician should be brought in to see the patient for the new problem and establish a plan of care. This should not pose a problem for the physician as under the 'incident to' guidelines, the physician has to be on site in the office suite. Another option is for the NP to see the patient and report the service under the NP's Medicare provider number."

Unless and until Medicare administrators provide further guidance, either of these approaches would be appropriate.

Copyright 2006, Carolyn Buppert
This article is taken from The Green Sheet, published monthly from the Law Office of Carolyn Buppert. To order, click here. For more detail on billing nurse practitioner services, see 'Billing Physician Services Provided by Nurse Practitioners is Specialists' Offices, Hospitals, Nursing Facilities, Homes and Hospice." To order, click here.

Billing "incident to" when an established patient has a new problem