- C—The patient will become a new patient again in three examples:
- Physician has not seen the patient within three years;
- Physician’s associate with the same specialty has not seen the patient within three years; and
- Physician or physician’s partners must not have seen the patient within three years, even if it was in another practice. For example, if a provider takes on a new partner and the partner brings on his/her patients, they cannot be seen as a new patient by anyone of the same specialty in the new practice or in the old practice within three years.
- A—Only the treating provider or healthcare professional is allowed to take the history of present illness. Note that it is important to check your payer or contractor policy on recording of the patient’s history of present illness at each encounter. For example, Wisconsin Physician Services has a Q&A on its website
(http://www.wpsmedicare.com/j5macpartb/resources/provider_types/2009_0526_emqahistory.shtml) addressing the history element and clearly states the following:
Q 18. Who can perform the History of Present Illness (HPI) portion of the patient’s history?
A 18. The history portion refers to the subjective information obtained by the physician or ancillary staff. Although ancillary staff can perform the other parts of the history, that staff cannot perform the HPI. Only the physician can perform the HPI.
Q 19. If the nurse takes the HPI, can the physician then state, “HPI as above by the nurse” or just “HPI as above in the documentation”?
A 19. No. The physician billing the service must document the HPI.
- B—According to the CMS Medically Unlikely Edits, only one ultrasound guidance code (76942) can be billed within a 24-hour period per patient. Remember, Medicare has often reimbursed for procedures and then gone back and recouped payments after a payment review; therefore, providers should make sure to review all carriers’ medical policies for reimbursement updates.
- A—For the physician to bill for an incident-to service, a patient must be an established patient with an established diagnosis. Keep in mind that if an NPP sees a new patient or an established patient with a new problem without any physician involvement and assessment, the charges will have to be billed under the NPP’s personal national provider identification number and receive reimbursement at 85% of the approved Medicare Part B Fee Schedule payment. Also, the following criteria must be met for every encounter. It must be:
- An integral, although incidental, part of the physician’s professional service;
- Commonly rendered without charge or included in the physician’s bill;
- Of a service type commonly furnished in physicians’ offices or clinics; and
- Furnished by the physician or ancillary personnel under the physician’s direct supervision.
- No. In order to receive reimbursement for an incident-to billing on an established patient, there must be more documentation than a provider statement that he or she agrees with the NPP notes. The rheumatologist must add their own findings in the note, which should be identifiable and separate from the NPP’s note.
Note: The incident-to rule applies only to Medicare patients. A provider or office staff must check with all private payers to ask about their rules for NPP services.