Q: Under incident-to guidelines, does the physician have to see the patient for the initial new problem? If the physician assistant (PA) sees the patient for two visits, then our physician sees them and develops a new plan of care, can the PA carry out that plan of care and bill incident-to?
A: In the scenario you explained, these first two visits do not meet the incident-to guidelines, so the PA would bill the two visits under his/her (NPI) if the insurance company being billed credentials PAs. If the payer does not credential PAs, the claim would need to be billed under the supervising physician, meaning the physician on-site in the clinic when the services are rendered.
Once the physician sees the patient and develops the plan of care, the PA can bill the subsequent services under the physician’s NPI if the payer recognizes incident-to guidelines. If the payer does not follow incident-to guidelines, the PA billing would follow my explanation in the first paragraph.
In our area of the country, we have only two payers who follow incident-to guidelines: Medicare and Aetna. Therefore, for all other payers we ask the following question to know how to bill the claim.
Does the payer credential the practitioner providing the services?
Yes—Bill under the practitioner’s NPI.
No—Bill under the NPI of the physician who is in the office at the time of service. Incident-to guidelines do not apply because the payer does not recognize them.