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?

Medicare incident-to billing in a physician office requires, among other elements, that the service relate to a physician’s established plan of care. When an advanced practice provider in a civic primary-care clinic evaluates a Medicare patient for a brand-new problem and the physician has not personally performed the initial service or established a plan for that problem, incident-to requirements are not met. The compliant approach is to follow direct billing rules applicable to the APP rather than billing under the physician NPI at 100%. That distinction protects public-program payment integrity when the supervisory and plan-of-care gates are absent.

Billing under the physician NPI at 100% because any office APP visit supposedly qualifies fails by concept because incident-to is conditional, not automatic for every APP encounter. Billing incident-to merely because a nurse later adds the physician’s name fails because cosmetic name insertion does not create a physician-established plan of care or supervision construct. Restricting physician-NPI billing only to patients never seen in the practice for any reason fails because incident-to turns on problem-specific plan-of-care and supervision rules, not a once-in-a-lifetime new-patient myth.

Exam caveat: after a physician establishes a plan for the problem and other incident-to conditions are met on a later visit, incident-to may become available; the tested scenario is the new problem without that foundation. Operational check: before selecting physician NPI for an APP visit, verify the problem is being managed under an established physician plan and that supervision/employment gates are met; otherwise bill under the APP.