• Zach Stephens

Incident To Billing in a Physician Practice

Employing non-physician practitioners (physician assistants, nurse practitioners, clinical nurse specialists, etc.) is an effective way to increase productivity in a physician's office. However, under Medicare rules, covered services provided by non-physician practitioners (NPPs) are reimbursed at a reduced rate (85 percent of the fee schedule amount).


The “incident-to” billing rules provide an exception, allowing 100 percent reimbursement for non-physician services that meet the requirements detailed in the Medicare Benefit Policy Manual, Chapter 15, Section 60 (Services and Supplies Furnished Incident To a Physician’s/NPP’s Professional Service).


When billing Medicare incident to, there are six main requirements that you must follow to stay in compliance with their guidelines.


The Six Requirements


One: The service must take place in a “non-institutional setting, which the Centers for Medicare & Medicaid Services (CMS) defines as “all settings other than a hospital or skilled nursing facility". Per the Benefit Policy Manual, “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.”


Two: A Medicare-credentialed physician must initiate a patient’s care. If the patient has a new or worsened complaint, a physician must conduct an initial evaluation and management (E&M) for that complaint and must establish the diagnosis and plan of care. Incident-to services cannot be rendered on the patient’s first visit, or if a change to the plan of care (e.g., medication adjustment) is required.


Three: Subsequent to the initial encounter (during which the physician arrives at a diagnosis and plan of care), an NPP may provide follow-up care. This care must occur under the “direct supervision” of a qualified provider. Per the Benefit Policy Manual: 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 provide assistance 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 in an institution (other than a hospital or skilled nursing facility), 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]. The supervising physician does not have to be the physician who performed the initial patient evaluation. Any physician member of the group may be present in the office to supervise.


Four: A physician must actively participate in and manage the patient’s course of treatment. The exact requirement is usually defined by the state licensure rules for physician supervision of NPPs (e.g., the physician must see the patient every third visit).


Five: 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).


Six: The incident-to service must be the type of service usually performed in the office setting, and must be part of the normal course of treatment of diagnosis or illness. The Benefit Policy Manual elaborates: 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.


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 performed the service, and that a supervising physician was in the office suite (although not necessarily the same room), at the time of the service.


Is Your Practice Non-Compliant?


You must self-disclose this overpayment. In fact, you only have a limited amount of time to do so. If you have no idea how to begin this process then we can help; however, you must take action immediately. In addition to self-disclosure, we can help enact policies in your practice to prevent this issue from occurring again.


Give us a call today at 202-681-3085 should you have any questions or concerns. Our firm is ready to help.


The contents of this blog are intended for educational/informational purposes only and do not constitute legal advice. Readers are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and/or change over time.