Coding and Billing Guidelines when PA Sees a Patient: Incident-to-Services

In 1977, the U.S. government passed The Rural Health Clinic Service Act, signed by President Carter, to address the shortage of rural physicians for Medicare beneficiaries. This act established Rural Health Clinics to improve access to care by utilizing Nurse Practitioners (NPs) and Physician Assistants (PAs).

Later, The Balanced Budget Act of 1997 standardized their reimbursement rates at 85% of the physician fee schedule and removed restrictions on where they could provide services, enhancing patient care in all settings.

When using a billing modifier when a PA sees a patient, incident-to-billing services allow you to bill under the supervising physician’s NPI (National Provider Identifier), provided the physician initiates care and is present during treatment. This method can lead to higher reimbursement rates, including from Medicare, ensuring that your services are compensated at the full physician rate.   

In this article, SPRY PT highlights the process of how incident-to-billing is allowed with a Billing modifier when a PA sees a patient. 

What is Incident-To Billing Services?

In medical billing and coding, you can use incident-to-billing services to receive full physician-level reimbursement for services provided by your Non-Physician Practitioners (NPPs), such as Physician Assistants (PAs) and Nurse practitioners (NPs), as long as Medicare guidelines are met. This approach allows you to bill for services under the supervising physician’s National Provider Identifier (NPI), often resulting in higher reimbursement rates.

The purpose of this is to ensure complete reimbursements at the total physician rate. This indicates that the services were delivered as part of the physician’s care plan, helping you avoid audits and claim denials while maximizing your practice's revenue. 

Key Requirements for Incident-To Billing

To benefit from incident-to-billing, you must meet specific requirements to avoid billing issues, increase revenue, and stay compliant with Medicare regulations.

1. Incident-To Services Must Be an Integral Part of the Physician's Service

According to Medicare, services that aren’t tied to the physician’s diagnosis or plan cannot be billed as Incident-To services.

For Example,

A physician diagnoses a patient with Type 2 Diabetes (CPT Code 95250) and provides a treatment plan that includes blood sugar monitoring, medication management, and dietary counseling. 

The PA can follow up on medication adjustments, check blood sugar levels regularly, and review diets that are aligned with the plan, qualifying for incident-to-billing.

CPT Code 99213: This code can be considered when:

• Conducting detailed office visits for established patients
• A PA monitors blood pressure and reviews treatment plans
• Adjusting medications as necessary
• Providing follow-up care for diabetes management, including medication adjustments and lifestyle counseling by a PA
  
  

2. Physician's Initial Consultation and Active Involvement

For incident-to-billing services to work, the physician must have conducted the initial consultation and created the treatment plan for the patient.

Suppose a physician creates a Hypertension (CPT 99473) treatment plan for a patient. A PA can conduct regular check-ups, monitor blood pressure, adjust recommendations, and coordinate with the physician on treatment updates, but only after the physician’s initial consultation. 

These services qualify for incident-to-billing due to the physician's ongoing involvement. 

CPT Code 99214:  This code can be considered when: 

• Conducting detailed office visits for established patients
• A PA monitors blood pressure
• Reviewing treatment plans
• Adjusting medications if necessary

Managing patient data can be complex, especially when dealing with large volumes of information across different systems. If you are looking for software that provides an all-in-one solution for clinics with EMR, integrated billing, and patient management, you must consider SPRY PT. Check out the Pricing here! 

3. Direct Supervision Requirements

Another critical requirement is that the physician provides direct supervision during care. 

For example:

A physician diagnoses spinal stenosis (M48.00/ICD-10-CM) and plans physical therapy and medication for a patient. The PA manages follow-ups, tracks progress, and adjusts meds under physician supervision, qualifying for incident-to-billing.

CPT Code 97110: This code is considered in such cases. Especially when, 

• Therapeutic exercises as a treatment to enhance mobility and strength
• PA monitors integral to spinal stenosis treatment plans
• PA also helps in improving the range of motion and muscle function
  
  

4. Documentation Essentials

Accurate documentation is equally essential for incident-to-billing compliance. 

For example:

A physician develops a COPD treatment plan (CPT 99490) with inhalers, rehab, and lifestyle changes. The PA manages follow-ups, assists with medical device usage, and adjusts medications based on lung function tests, thereby enabling incident-to billing.

CPT Code 94664: This Code allows you to 

• Demonstrate proper use of inhalers or nebulizers to patients.
• Assess and evaluate the patient’s technique to ensure effective medication delivery.
• Provide education on correct device usage to enhance treatment outcomes.
• Include follow-up evaluations to monitor and improve the effectiveness of the inhaler or nebulizer.

Practices require documentation tools in such cases. Platforms like SPRY PT offer documentation and digital intake services that help you with fewer errors and avoid costly compliance issues. Subscribe to SPRY here! 

Let us also understand the essential responsibilities and qualifications that Physician Assistants (PAs) need for incident-to-billing services to maintain compliance and ensure smooth operations.

The Role of Physician Assistants in Incident-To Services

Understanding the responsibilities, collaborating with the supervising physician, and using correct E&M codes allow you to streamline incident-to-billing and improve reimbursement. To be eligible for incident-to-services, let’s briefly understand the role of a Physician Assistant (PA).

1. Certified Physician Assistant (PA-C) Responsibilities

The role of a Certified Physician Assistant (PA-C) in incident-to-billing includes key responsibilities that ensure seamless patient care while adhering to Medicare’s billing requirements. These responsibilities include:

• Eligibility Fulfilment: You must be licensed by the state where you practice, graduate from an accredited PA program, and pass the national certification exam administered by the National Commission on Certification of Physician Assistants (NCCPA).
• Follow-Up Care: Manage and deliver patient care that follows the treatment plan initially set by the supervising physician.
• Medication Management: Adjust medications as needed based on patient progress, lab results, or other clinical findings, always in line with the physician’s plan.
• Patient Monitoring: Monitor chronic conditions, track treatment outcomes, and update the supervising physician on significant changes.
• Documentation: Ensure thorough and accurate documentation of patient care, including progress notes and treatment modifications, to comply with billing and Medicare requirements.
• Patient Education: Educate patients on their condition, treatment plans, medications, and lifestyle changes, reinforcing the physician’s initial guidance.
• Collaboration: Work closely with the supervising physician, ensuring they remain actively involved in the care process by reviewing notes and discussing potential adjustments to the treatment plan.
• Compliance with Guidelines: Adhere to Medicare’s incident-to-billing requirements, including ensuring the physician is present in the office suite during care and that services are an integral part of the physician’s treatment plan.

These responsibilities help ensure the PA-C can deliver quality patient care while also meeting the necessary criteria for incident-to-billing.

Give this a watch on YouTube for a better understanding of Incident-To-billing. The Medical Coding Cert webinar discusses an overview of the billing process - Incident-to-billing Clarification. 

2. Evaluation and Management (E&M) Codes Applicable: CPT Code 99211 to 99215

Evaluation and Management (E&M) codes are important to represent the services provided in Incident-To-Billing accurately. PAs commonly use codes like 99211-99215 to describe office visits for established patients. For example:

1. CPT 99211: This code is used for a very low-complexity office visit, typically involving minimal physician time (typically 5 minutes) and no medical decision-making. It may involve simple tasks like checking blood pressure or refilling prescriptions.
2. CPT 99212: This code is for low-complexity office visits, usually involving a brief patient history or examination. It generally includes medical decision-making of low complexity and covers visits lasting around 10 minutes.
3. CPT 99213: This moderate-complexity code is used for visits involving the evaluation and management of an established patient. It includes moderate decision-making, such as medication adjustments for conditions like hypertension or diabetes, and covers visits lasting around 15 minutes.
4. CPT 99214: This code applies to more complex visits involving a detailed history, examination, and medical decision-making of moderate to high complexity. It is often used for ongoing management of chronic conditions like COPD, and the visit typically lasts around 25 minutes.
5. CPT 99215: This code is for the highest complexity visits involving extensive history, comprehensive examination, and high-complexity medical decision-making. It is used for serious, chronic conditions requiring significant time and medical expertise, generally for visits lasting around 40 minutes.

Each of these codes must accurately reflect the complexity of the services provided, and the documentation must support the E&M level chosen to comply with Medicare’s guidelines and ensure proper reimbursement.

SPRY PT’s Physical Therapy Management software streamlines note-taking, giving therapists more time to focus on patient care instead of documentation and compliance. Explore SPRY PT’S features today!

Billing Process for Incident-To Services: Using the Physician’s NPI

The Incident-To services billing process ensures accurate billing while adhering to Medicare and insurer guidelines using the physician’s NPI. Below is a brief overview of the steps involved in billing for Incident-To-services. 

1. Initial Consultation:

• Physician Evaluation: The supervising physician conducts the first patient visit.
• Treatment Plan: Develop and establish a comprehensive treatment plan.
• Qualification: Ensures the treatment plan qualifies for incident-to-billing.
  
  

2. Delivery of Care by NPP: 

• Follow-Up Care: A Physician Assistant (PA) or Non-Physician Practitioner (NPP) provides ongoing care.
• Adherence: Services must directly relate to the original treatment plan.
  
  

3. Physician Supervision:

• Direct Supervision: The physician remains physically present in the office suite during care delivery.
• Availability for Consultation: The physician is available for immediate consultation if needed during the NPP’s care.
  
  

4. Physician Involvement Documentation:

• Record Keeping: Document initial involvement and any updates or collaborative decisions with the NPP. Platforms like SPRY PT help maintain neat documents and Keep your patient medical information organized and easily accessible. Check out the features here. 
• Support Billing: Ensures documentation supports the incident-to-billing process.
  
  

5. Use the Physician’s NPI for Billing:

• Billing Identifier: Submit reimbursement claims using the physician’s National Provider Identifier (NPI) to indicate incident-to-services.
  
  

6. Correct Selection of CPT Code:

• Appropriate Coding: Choose the correct Evaluation and Management (E&M) CPT code (e.g., 99211-99215) based on the complexity of the visit.
  
  

7. Claim Submission:

• Comprehensive Documentation: Ensure all visit details are thoroughly documented.
• Submit Claim: Use the physician’s NPI to submit the claim to Medicare or the appropriate insurer.
  
  

8. Monitor Claim for Approval:

• Track Progress: Monitor the status of the submitted claim.
• Address Issues: Resolve any issues, such as denials due to improper documentation or incorrect coding, to avoid reimbursement delays.

Suggested Read: Essentials of Physical Therapy Billing: How Software Simplifies the Process

Medical practices commonly follow the above steps to optimize the billing process. It is essential to recognize key modifiers and understand how to manage claim denials in unfortunate situations. 

Common issues, like incorrect coding or insufficient documentation, can lead to denials. Let’s briefly review the key modifiers for Physician Assistants (PAs) in Incident-To billing.

Modifiers and Denial Management

Recognizing common modifiers for physician assistants and addressing reasons for claim denial, such as incorrect coding or insufficient documentation, is essential. Now, let's briefly review key modifiers in Incident-To Billing for PAs.

Common Modifiers that are Applicable

Modifiers provide additional information about the performed service. Common modifiers include:

• Modifier SA: Indicates services performed by a Physician Assistant under the supervision of a physician.
• Modifier 25: Used when a significant, separately identifiable Evaluation and Management (E&M) service is provided by the same provider on the same day as another procedure.
• Modifier 59: Used to indicate distinct procedural services that are not typically reported together.
• Modifier 95: Denotes telemedicine services.

While platforms like SPRY PT streamline billing efficiency, it's essential to understand and avoid common medical billing pitfalls. Let’s explore the most frequent mistakes that the practices usually see. 

Common Pitfalls to Avoid in Medical Billing

1. Incorrect Use of Modifiers: Failing to apply the appropriate modifiers (e.g., modifier SA for incident-to-services) can lead to claim denials or improper reimbursement.
2. Inadequate Documentation: Insufficient or unclear documentation regarding patient care, physician involvement, and supervision can result in denied claims or audits.
3. Improper Coding: Using the wrong CPT codes or billing codes that don’t accurately reflect the level of service provided can cause delays in reimbursement or potential underpayments.
4. Failure to Meet Incident-To Requirements: Not following Medicare’s incident-to guidelines, such as the physician’s presence during care, can disqualify services from being billed incident-to.
5. Ignoring Eligibility and Coverage Checks: Failing to verify patient insurance eligibility and coverage before providing services can result in claim rejections and revenue loss.
6. Missing Deadlines for Appeals: Neglecting to file appeals for denied claims within the insurer's deadline can cause the practice to miss out on potential reimbursement opportunities.
7. Neglecting Regulatory Updates: Not staying updated with changes in Medicare or insurance billing guidelines can result in non-compliant billing practices and possible fines.

Avoiding these common pitfalls helps ensure smooth and accurate billing processes, improving reimbursement outcomes while reducing errors and compliance risks.

Appeal Process and Documentation

When a claim is denied, understand the reason for the denial (e.g., incorrect coding or missing documentation.

The appeals process involves:

• Gathering Documentation: Collect all relevant patient records, physician notes, and correct modifiers to support the claim.
• Submitting an Appeal: Write a clear, detailed appeal letter explaining the error, supported by documentation. Ensure that appeal deadlines set by the payer are met.

Optimize billing efficiency and boost reimbursements by using correct modifiers, maintaining accurate documentation, managing denials, and staying updated on 2024 compliance changes. Let's also review the latest policy updates.

Compliance and Policy Updates as of 2024

The 2024 Medicare compliance updates bring significant changes in reimbursement rates, telehealth services, and CPT code modifications, impacting billing and practice management. The Updates are as follows:

1. Medicare Physician Fee Schedule (MPFS) Changes:

• 3.37% reduction in the Medicare conversion factor, dropping to $32.7442 in 2024 from $33.8872 in 2023.
• The Introduction of a new add-on code (G2211) for complex visits aimed at alleviating the impact of payment reductions for primary care physicians​.

2. Telehealth Services Extension:

• Telehealth reimbursement parity with in-person visits extended through December 31, 2024.
• Continuation of telehealth billing for services across various specialties, including audiology and speech-language pathology​.

3. Remote Therapeutic Monitoring (RTM) Adjustments:

• Billing requirements clarified that RTM data collection needed to occur for at least 16 days within 30 days.
• Only one clinician is allowed to report RTM services during this timeframe​.

4. CPT Code Updates for 2024:

• 349 total changes to the CPT code set, including 230 new codes, 70 revisions, and 49 deletions.
• Focus on simplifying Evaluation and Management (E&M) coding to align with Medicare requirements​. 

These policy updates ensure that healthcare providers can stay updated with the evolving regulatory landscape and improve reimbursement with Medicare guidelines in 2024.

Suggested Read: Guide to the Medicare's 8-Minute Rule

Practical Application and Scenarios of Incident-To-Billing

Practical applications and scenarios are important for effectively applying policies and guidelines in real-world situations. Below are some of the practical scenarios that you might encounter when considering Incident-to-Billing Services.

1. Inpatient Incident-To Billing Scenario

A 72-year-old female retired teacher had been struggling with severe hip pain for years due to degenerative osteoarthritis (M19.90). After an initial consultation, her physician determined that a total hip replacement was necessary. Following the surgery, the physician developed a recovery plan, including pain management, physical therapy, and regular assessments. 

• Illness: Hip Osteoarthritis
• Diagnosis by Physician: Severe degenerative osteoarthritis requiring total hip replacement surgery (CPT Code 27130).
• Treatment Plan by Physician: After surgery, the physician prescribes a treatment plan involving pain management, physical therapy, and close monitoring of recovery progress.

PA Role: The PA provides post-surgical follow-up care, monitors pain levels, manages medications, and oversees the patient's progress in physical therapy. The physician is in the hospital, ensuring the PA’s services qualify for incident-to-billing. (CPT Code 99233).

2. Outpatient Incident-To Billing Scenarios

A 60-year-old male with a history of Type 2 Diabetes Mellitus (ICD-10-CM E11.9) presented to the clinic with poorly controlled blood sugar levels despite previous treatments. After a thorough evaluation, the physician initiated a new regimen, combining insulin therapy with oral antidiabetic medications and dietary counseling. 

The PA took charge of the patient’s follow-up care, adjusting his insulin doses based on blood glucose readings, reviewing his diet, and ensuring adherence to the treatment plan. 

• Illness: Type 2 Diabetes Mellitus
• Diagnosis by Physician: Uncontrolled diabetes, requiring medication adjustment and regular monitoring of blood glucose levels.
• Treatment Plan by Physician: The physician starts the patient on a combination of insulin therapy, oral antidiabetic medications, and dietary counseling.

PA Role: The PA manages follow-up visits, adjusts insulin doses based on blood sugar readings, reviews diet plans, and monitors the patient’s adherence to the treatment. The physician is on-site, ensuring the PA’s services can be billed under incident-to guidelines, which comes under moderate-complexity visit billing (CPT Code 99213). 

Now, let's look at practical examples that highlight compliant billing practices in various scenarios.

Real-world Examples of Medical Billing Practices Across Healthcare Services

These practical examples demonstrate how following guidelines, applying correct CPT codes, and documenting care can help you remain compliant while enhancing reimbursement accurately.

1. Incident-To Billing Example:

As we already discussed, in Incident-to-billing, the Physician Assistant follows up with a diagnosed patient, adjusts medications per the physician’s plan while the supervising physician is present, and documents all changes and patient progress.

For compliant billing, the service is billed under the physician’s NPI with CPT code 99213, and the SA modifier is used to indicate the PA's role. This ensures full reimbursement at the physician rate while adhering to Medicare’s incident-to guidelines.

2. Telehealth Services Example:

A doctor performs a COPD telehealth visit (CPT 99441), indicating an audio-only telehealth visit. The PA adjusts medications, provides symptom management guidance, and ensures accurate documentation to comply with 2024 Medicare telehealth requirements.

3. Split/Shared Visit Example:

In a hospital, a Nurse practitioner (NP) evaluates a Congestive Heart Failure (CHF) patient. Then, the physician reviews and finalizes treatment and care. Both actions are documented, and the visit is billed under the physician’s NPI with CPT 99233 for Medicare 2024 split/shared billing.

4. Preventive Care Example:

A patient comes in for an annual wellness visit, where the physician conducts a comprehensive physical exam and reviews the patient’s health risks. 

The service is billed using CPT code 99396 for an annual preventive exam for an established patient. Proper documentation includes the patient's history, the exam details, and any recommendations or follow-ups, ensuring the billing is compliant with Medicare's preventive care guidelines.

5. RTM Services Example:

A physical therapist remotely monitors a patient recovering from knee surgery by tracking their progress through the SPRY PT’s EMR for 16 days within a 30-day period. The PT ensures that all data, including patient feedback and exercise compliance, are documented neatly within the software. 

This Remote Therapeutic Monitoring (RTM) service is billed using CPT code 98977, following Medicare’s guidelines for remote patient care management.

Platforms like SPRY PT are physical therapy management software that focuses on features such as EMR (Electronic Medical Record), billing, and patient management. They provide integrated billing, digital intake, appointment scheduling, and analytics. Try it here for free! 

Conclusion

To ensure successful incident-to-billing services, focus on accurate coding, detailed documentation, and strict adherence to Medicare guidelines for the PAs and NPPs. By following these practices, you maximize reimbursement and avoid errors. 

In these cases, comprehensive software solutions can help with better workflows and keep you updated on evolving regulations, ensuring smoother billing processes for your practice.

Platforms like SPRY PT  provide an all-in-one solution for clinics, focusing on features such as EMRs, Integrated billing, Insurance verification, and patient management. SPRY PT addresses pain points by offering an integrated platform that streamlines clinic operations, reducing the need for multiple tools. Book a Free Demo here!