“Incident-to” Top 17 Billing Requirements

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Incident to billing allows non-physician providers (NPPs) to report services “as if” they were performed by a physician. The advantage is that, under Medicare rules, covered services provided by non-physician providers (NPPs) are typically are reimbursed at 85 percent of the fee schedule amount, whereas, services properly reported incident to are reimbursed at 100 percent of the full fee schedule value.

 

The Top 17 things to know about “Incident to” billing requirements:

  1. Although certain non-physicians practitioners (NPPs) may bill Medicare independently for their services, those services generally are paid at a lesser rate (typically 85 percent of fee schedule); whereas, Medicare reimburses for services properly reported incident to at 100 percent of the fee schedule amount.
     
    1. Incident to billing requirements are detailed in the Medicare Benefit Policy Manual, Chapter 15, Section 60.
       
      1. Incident to billing applies only to Medicare.
      2. Incident to billing does not apply to services with their own benefit category

          

        For Example:


        Diagnostic tests are subject to their own coverage requirements.

         

         

        “Depending on the particular tests, the supervision requirement for diagnostic tests or other services may be more or less stringent than supervision requirements for services and supplies furnished incident to physician’s or other practitioner’s services. Similarly, pneumococcal, influenza and hepatitis B vaccines do not need to meet incident-to requirements.”

         

        A supervising physician does not need to be physically present for flu shots, EKGs, Laboratory tests, or X-rays performed in an office setting in order to be billed as “incident to” services. These services have their own statutory benefit categories and are subject to the rules applicable to their specific category. They are not “incident to” services and the “incident to” rules do not apply.


      3. Incident to billing services must take place in a "noninstitutional setting," which the Centers for Medicare and Medicaid Services (CMS) defines as: 

         


        "all settings other than a hospital or skilled nursing facility."

         

        Hospital services incident to physician’s or other practitioner’s services rendered to outpatients (including drugs and biologicals which are not usually self-administered by the patient), and partial hospitalization services incident to such services may also be covered.

         

        1. Incident to services cannot be rendered on the patient’s first visit, or if a change to the plan of care occurs.
        2. A Medicare-credentialed physician must initiate the patient’s care.

           

          1. If the patient has a new or worsened complaint, a physician must conduct an initial evaluation and management (E/M) service for that complaint and must establish the diagnosis and plan of care.

           

          1. Subsquent to the encounter during which the physician establishes a diagnosis and initiates the plan of care, a non-physician provider (NPP) may provide follow-up care under the “direct supervision” of a qualified provider.

           

          1. Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to help and direction throughout the time the aide is performing services.

            If auxiliary personnel perform services outside the office setting, e.g., in a patient’s home or an institution (other than hospital or SNF), their services are covered incident to a physician’s service only if there is direct supervision by the physician [e.g., the physician must be physically present to oversee the care].

             

            1. Any physician member of the group may be present in the office to supervise. The supervising physician does not have to be the physician who performed the initial patient evaluation.

             

            1. physician must “actively” participate in and manage the patient’s course of treatment. This requirement typically is defined by individual state licensure rules for physician supervision of non-physician providers (NPPs).

             

            1. Both the credentialed physician and the qualified NPP providing the incident to service must be employed by the group entity billing for the service. If the physician is a sole practitioner, the physician must employ the NPP.

            2. The incident to service must be of a type usually performed in the office setting and must be part of the normal course of treatment of a diagnosis or illness.

              Where supplies are clearly of a type a physician is not expected to have on hand in his/her office or where services are of a type not considered medically appropriate to provide in the office setting, they would not be covered under the incident to provision.”

               

              1. Documentation must establish and support incident to billing requirements.

               

              Services meeting all of the above requirements may be billed under the supervising physician’s NPI as if the physician personally performed the service.

               

              Documentation should detail:

              - who perfomed the service

               

              - a supervision physician was in the office suite at the time of the service.

               

              1. Services delivered by auxiliary personnel incident to a physician’s services are coded normally, using standard CPT, ICD-10-CM, and HCPCS codes, without additional modifiers, and are billed under the supervising physician’s provider ID.

               

              1. Additional rules apply for incident-to billing of physician’s services in a clinic, and services incident to a physician’s service to homebound patients under general physician supervision.

             


Incident To Blog Graphic

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Topics: Medicare Billing


Kris Mastrangelo, OTR/L, LNHA, MBA

WRITTEN BY

Kris Mastrangelo, OTR/L, LNHA, MBA
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