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Incident To and Direct Billing.


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I wanted to ask some of you billing gurus on a subject.  So up until recently we were billing incident to and I did bring up the fact that we should not be doing this.  On a number of occasions, they were billing this even when the physician was not in the building.  Upon further reading it also appears that in order to bill incident to that the MD must see the patient for the initial visit.  Our practice is a single MD and he does not see new patients except for a rare occasion (10 a year).  I brought this up to our practice manager with an article from CMS stating this and she stated that there was a loop hole somewhere.  After about 1.5 months she finally admitted in a meeting that we could definitely not bill incident to when our MD is out of clinic.  She is now telling us that we can use direct billing for the initial visit and then incident to for the billing thereafter.  According to CMS to bill incident to at all the new patient has to have their initial visit completed by the MD.  She states that she talked to a “billing expert” and this is not the case.  She once again stated that we can do direct billing for the initial visit and incident to on the follow up visit.  Can someone direct me to someone in Medicare I can talk with in order to confirm or permanently correct her?  I am also open to education on the forum here if things have changed.  My MD is a good man but has gotten bad advice in the past on billing.  She did admit that she missed some of the incident to rules on her watch, but she also holds herself to be a billing professional as well.  Any information would be greatly appreciated as I do not think we can bill through the MD based on incident to guidelines per Medicare.  I do not mind fighting with her on this but I want some data and opinions on this before I go digging a trench for myself. 

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Incident to is relatively simple. The physician must see the patient and form the plan for each new problem. If a patient is new, then the physician must see the patient. If the patient develops a new problem then the physician must see the patient. The AAPC has a good article on this:

https://www.aapc.com/blog/44912-seven-incident-to-billing-requirements/

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This is a big issue that I faced many times in my career, including at Mayo Clinic. I was required to bill "Incident to" (as you know better revenues) but as you are arguing, it did not follow the CMS rules. Mayo wasn't trying to be deceitful, but even they were reading the laws wrong. We finally fix it where all my billing was independent as it made no sense to have an attending see my patient  first. But I had two other clinics try to do the same thing. When I owned my own clinic I followed the letter of the law and coloradopa has stated it well.

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We did this in my old practice.  The Physician saw all the new patients and then I saw them in follow up.  It met incident too most times as he was in the office most of the time, but then the patient comes in for their back and they say "My shoulder is killing me"  then bam, does not meet incident too.  It was a pain in the A** to try and keep track of.  

I have since left that job and now we bill direct for everything and it makes it much simpler.  And much lower risk of committing fraud. 

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  • 3 weeks later...

Thank you for the responses and I am currently working on this as I have presented it a number of times.  She has finally admitted that they are going to change and have the SP see all new Medicare patients.  This was after insisting that everything.  By doing research I noted that some BCBS do not even recognize indecent to billing.  She states ours in Texas does allow this, but is mum on the details.  I have reached out to the specific rep to get more details on this since I would think if you are going to pay full price you would want the SP involved and documented.  Should I find an issue again I plan on discussing this with the higher ups.  We also have no way to prove how things are getting billed at this time, and is still a work in progress.

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  • 3 weeks later...

Blue Cross in Michigan you can bill under the physician billing numbers ( therefore getting 100% reimbursement ) if you discuss the case either before or after the visit with the physician on the same day. You have to document this discussion in the note. 

 

i.e. you see the patient, you treat the patient, you discuss the treatment at some point during the same day with physician, you document said conversation, the patient gets billed under the physician billing numbers. 

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