This Week’s Auditing & Compliance Tip Comes from a Recent NAMAS Q&A

by  Shannon O. DeConda, CPC CPC-I CEMC CEMA CPMA CRTT
May 6th, 2016 - Reviewed/Updated Aug 16th

In the setting of incident-to billing, if an established patient presents with a known history of benign lesions including actinic keratosis previously treated by cryo, would the presence of new skin lesions be considered a 'new problem' that requires physician involvement OR is the previous history and treatment plan sufficient to satisfy an established plan of care and incident-to under the NPP alone supported?

We felt this question was a good tip as it crosses over many specialties, even though the actual wording of the question is dermatology specific. So to rephrase, If the patient presents for a problem they have previously been treated for, could the encounter meet incident-to guidelines as an established problem of an established patient?

This is a great question, and I think many of you that read this will have a split decision of half of you saying yes it meets incident-to and the other half saying no it does not. While the problem is a condition the patient has been treated for previously it was under a separate episode of care, and that episode of care was a completed course of treatment with a unique plan regarding that specific lesion with no "ongoing" associated treatments or plans regarding further lesions. Yes, I know the next question will be, well can we make our plan of care encompassing for that lesion and all future lesions? And, I think that additionally helps to answer this question, which really is clinical in nature (and I am not a practicing clinician but think the answer is reasonable), for good responsible medical care could there really be one universal plan of care for all presenting lesions? For which I think we would all (even as non-clinician's) would agree this does not sound reasonable.

Under the guides of incident-to we recognize that the guidelines are met for an established problem when the plan of care remains the same and there are no associated changes needed. In our listed dermatology example, as well as our specialty generic scenario, the problem for which the patient is being treated has no defined current treatment plan and for that reason would not necessarily support the guidance of incident-to. Furthermore, as an auditor a good litmus test would be, when auditing such an encounter within the MDM would you give credit for the diagnosis as a new problem to the provider today or an established problem, and I think most auditors would agree it would be a new problem.

However, I would not be completely accurate if I did not elaborate that there are many health law attorneys who might say, well Shannon I must disagree that I could certainly make a case for a client presenting with such concerns, for which I would reply, I don't disagree with you, but in a proactive consulting role with a client I would advise that this utilizing incident-to in this way there is an associated higher risk of audit and it would depend on the client's risk tolerance. Remember, in our world of guidelines that are often times left vague and in need of interpretation, there is always room for argument. The question becomes- how much do you want to argue?