“Incident to” is a Medicare billing provision that allows services provided by a non-physician practitioner (NPP) in an office setting to be reimbursed at 100 percent of the physician fee schedule by billing with the physician’s NPI. According to the Medicare Benefit Policy Manual Chapter 12 “incident to”, is defined, in part, as “services furnished as an integral although incidental part of a physician’s personal professional service.”
To bill Medicare “incident to” for services provided by an NPP the following criteria must be met:
- The service performed must be one that is typically performed in a physician’s office.
- The service performed should be within the scope of practice of the NPP and in accordance with state law.
- The physician must personally treat the patient on the patient’s first visit to the practice or treat any established patient who comes to the office with a new medical condition. NPPs may provide follow-up care.
- The physician must be in the suite of offices (on-site) when the NPP is rendering the service.
A Medicare patient has been previously treated by the physician and diagnosed with hypertension. On a subsequent visit to the physician’s office, the NP saw the patient and evaluated his or her hypertension, reviewed medicines, etc. within the plan of care established by the physician on the initial visit. The physician or another physician within the group was on-site, at the time the NP saw and treated the patient. The NP may bill the office visit “incident to” under the on-site supervising physician’s NPI with full reimbursement to the practice.
Example of not “incident to”:
A 70-year-old patient is coming into the clinic for her 6-month check-up for CHF. She is doing satisfactory with her ongoing care and maintenance, and appropriate prescription refills are given. However, the patient also complained of left lower extremity pain and edema on several occasions with difficulty walking. The APN evaluated the patient under level 4 established patient guidelines and ordered a lower extremity doppler study and an recommended the next available appointment with the peripheral vascular physician to address these issues after testing. The 99214 is to be billed under the NP’s provider number and reimbursement from Medicare will be 85% of the allowable. (commercial plans may not allow this so check with your individual plan on this)
How are “incident to” services billed?
Services provided “incident to” are billed under the physician’s name and NPI.
What other requirements must be met before an NPP may bill under Medicare’s “incident to” provision?
- The NPP must be a W-2 or leased employees of the physician, and the physician must be able to terminate the employee and direct how the Medicare services are provided by that employee.
- The initial visit (for that condition) must be performed by the physician. This does not mean that on each occasion of an incidental service performed by an NPP, that the patient must also see the physician. It does mean, however, that there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the services being performed by the NPP is an incidental part.
- There must be direct personal supervision by the physician as an integral part of the physician’s personal in-office service. The physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary.
- The physician has an active part in the ongoing care of the patient. Subsequent services by the physician must be of a frequency that reflects his/her continuing active participation in, and management of, the course of the treatment.
What NPP employment criteria must be met under the “incident to” rules?
To be considered an employee for purposes of the “incident to” provision, the NPP performing an “incident to” service may be a:
- Full-time; or,
- Leased employee of the supervising physician, physician group practice, or of the legal entity that employs the physician who provides direct personal supervision.
A leased employee is an NPP working under the written employee leasing agreement which provides that:
- The non-physician, although employed by the leasing company, provides services as the leased employee of the physician or other entity; and
- The physician or other entity exercises control over all actions taken by the leased employee with regard to the rendering of medical services to the same extent as the physician or other entity would exercise such control if the leased employee were directly employed by the physician or other entity.
May a physician assistant (PA) or nurse practitioner (NP) see a new Medicare patient and/or a new condition and bill the service as “incident to?”
No. By definition, a practice cannot bill a new patient visit or for a new condition performed by a PA or NP under the supervising physician NPI number as “incident to.”
Can a PA or NP see a new Medicare patient? What about a Medicare patient who comes to the office when no physician is on-site?
Yes. A PA or NP may see and treat any Medicare patient and provide a service within his or her state law guidelines for scope of practice as long as the state’s supervision requirements are met. Since the “incident to” criteria have not been met, the claim should be submitted with the PA’s or NP’s NPI.
If a patient was initially diagnosed by one physician in a group practice and a PA or NP sees the patient for a follow-up visit for the same condition while a different physician in the group is within the suite of offices, may the service be billed “incident to?”
Yes. In Medicare’s eyes, all physicians within a group are interchangeable. In this situation the claim should be submitted with the NPI number of the physician who was within the suite of offices while the “incident to” visit took place. The ordering physician’s name and NPI would be listed on the CMS 1500 in Box 17.
Join us for an important webinar on Non-Physician Practitioner (NPP’s) on April 17th, 2019
“Incident to” under the CMS Medicare payer means that your physician can receive 100% of the allowable fee schedule payment when his/her NPP sees a patient.
But what are the rules to support these services?
All of your compliance questions are answered in this webinar on April 17th. Terry covers supervision, documentation, signatures and more in this webinar while also answering questions about new versus established patients, new versus existing conditions, and what private or commercial payers do.
BS, CPC, CCC, CEMC, SCP-CA, ACS-CA, CCS-P, CCS, CMSCS, CMCS, CMC, QMGC, QMCRC
Ms. Terry Fletcher is a healthcare coding and billing consultant based in Southern California. With over 30-years experience, Ms. Fletcher teaches over 100 specialty coding Seminars, Teleconferences and Webinars every year. You can find her CodeCast™ podcast series, focusing on Physician Coding, Billing, Reimbursement, compliance, and Medical industry revenue opportunities, on iTunes, Stitcher, TuneIn, and Google Play.