An APP in a physician office evaluates a Medicare patient for a brand-new problem. The physician has not personally performed the initial service or established a plan of care for that problem. How should incident-to billing be handled?
Select an answer to reveal the explanation.
Short Explanation
New problem, no physician plan yet—incident-to usually doesn’t unlock. It’s like billing a specialist’s rate for a consult the specialist never kicked off. Bill under the APP’s rules until the plan-of-care pieces are really there.
Full Explanation
Medicare incident-to generally contemplates services that are an integral part of the physician’s established course of treatment. New problems typically require the physician (or another qualifying practitioner under applicable rules) to initiate care; absent those conditions, the APP’s service should be billed under the APP per coverage rules, often at a reduced fee schedule amount. Retroactive name-stamping does not create incident-to eligibility.