Understand the Key Elements of ‘Incident-to’ Billing

Physician-owned multispecialty groups and practices benefit from utilizing nonphysician providers (NPPs) such as registered nurse anesthetists, physician assistants, and surgeon’s assistants. Under Medicare rules, covered services provided by non-physician practitioners (NPPs) are generally reimbursed at 85% of the professional fee schedule amount. In contrast, Incident-to billing allows non-physician providers (NPPs) to report services as if they were performed by a physician. Services reported as incident-to are reimbursed at the full professional fee schedule value. However, the Centers for Medicare & Medicaid Services (CMS) has strict guidelines for incident-to billing, and failure to comply with these rules can lead to fraudulent claims and financial penalties. To address the complexities, many physician practices choose to rely on professional medical billing services, ensuring proper billing in compliance with CMS guidelines and full reimbursement.

Basic Guidelines of Incident-to Billing

Medicare covers services from certain nonphysician practitioners (NPPs), including:

• Nurse practitioners
• Clinical nurse specialists
• Certified registered nurse anesthetists
• Certified nurse midwives
• Clinical psychologists
• Clinical social workers
• Marriage and family therapists
• Mental health counselors
• Occupational therapists
• Physician assistants

Services provided by NPPs that meet all of the following requirements can be billed under the supervising physician’s National Provider Identifier (NPI), as if the physician personally performed the service:

1. Incident-to billing is limited to professional services billed to Medicare and does not apply to services with their own statutory benefit categories. They are not “incident to” services and the “incident to” rules do not apply. For example, diagnostic tests have specific coverage requirements. In addition to this, pneumococcal, influenza, and hepatitis B vaccines are exempt from incident-to requirements.
2. The incident-to service must be of a type typically performed in an office setting and part of the regular treatment for a specific diagnosis or illness. Auxiliary personnel providing these services must be supervised by the physician. According to the Benefit Policy Manual, services or supplies not commonly available in a physician’s office or not appropriate for office settings are not covered under the incident-to provision.
3. Any physician in the group can supervise, and it doesn’t have to be the physician who performed the initial evaluation.
4. The physician or other listed practitioner who supervises incident-to services should bill for them.
5. Incident-to services are not allowed during the patient’s first visit or when there is a change in the care plan. A Medicare-credentialed physician must initiate the patient’s care. If a patient presents with a new or worsening condition, a physician must perform an initial evaluation and management (E/M) service, establish the diagnosis, and create the care plan. Medicare’s Benefits Manual also states that the physician must actively participate in patient care, though the physician does not need to personally provide services at each encounter that is incident-to.
6. After the physician has established a diagnosis and initiated a care plan, an NPP may provide follow-up care under the direct supervision of a qualified provider. The Benefits Manual clarifies that direct supervision in the office setting means the physician must be in the office suite and immediately available to assist, though not necessarily in the same room. If auxiliary personnel provide services outside the office setting, such as in a patient’s home or another institution (excluding hospitals or SNFs), direct supervision by the physician is required, meaning the physician must be physically present to oversee care.
7. Both the credentialed physician and the qualified NPP delivering the incident-to service must be employed by the billing group entity. If the physician is a sole practitioner, the NPP must be employed by that physician.
8. A physician must actively participate in and manage the patient’s treatment plan. This is generally determined by state licensure rules governing physician supervision of NPPs.
9. The service billed as incident-to must take place in a non-institutional setting, defined by CMS as any location other than a hospital or skilled nursing facility. However, the Benefit Policy Manual notes that certain hospital outpatient services and partial hospitalization services incident to physician or practitioner services may also be covered.

Documentation must clearly indicate who performed the service and confirm that a supervising physician was present in the office suite at the time of the service. Successful incident-to billing depends on knowing when and how to bill for services provided by someone other than the supervising physician. Partnering with an experienced medical billing company can be invaluable in this process. Their expertise can help your practice navigate the complexities of incident-to billing, reducing the risk of errors and maximizing reimbursement.

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Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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