“Incident to” and the Initial Medicare Visit

Novitas Solutions will deny or downcode claims for initial office visits billed as "incident to" when a nonphysician practitioner performs the initial history and physical.

Under Medicare rules, the physician must perform the initial service for each new patient to establish the patient-physician relationship. This includes the history and physical, the examination portion of the service, and the treatment plan. The physician's presence in the room or office suite while the nonphysician practitioner conducts an initial visit does not qualify this service for incident-to billing.

Novitas reports observing a "continued trend" of initial visits incorrectly billed as incident-to and offers these guidelines. In addition, read more information about billing (PDF) for nonphysician practitioner services from the Centers for Medicare & Medicaid Services, as well as the complete rules (PDF) in the Medicare Benefit Policy Manual.

If you have questions about billing and coding for Medicare (or other payer) policies, email a TMA reimbursement specialist for help at paymentadvocacy[at]texmed[dot]org, or call the TMA Knowledge Center at (800) 880-7955. TMA Practice Consulting can help with on-site coding and documentation training, or a comprehensive coding and documentation review. Continuing medical education credits are available with both of these paid services. In addition, TMA's Nonphysician Practitioners, Second Edition, explains all about working with these health care professionals. It is available in the TMA Education Center.

Published Nov. 11, 2014

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Last Updated On

December 20, 2016

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