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Key Elements of ‘Incident-to’ BillingMany physician-owned multispecialty groups and practices find it to their advantage to use nonphysician providers (NPPs). According to 2013 MGMA report, practices with NPPs perform better financially and generate higher physician income. NPPs include registered nurse anesthetists, physician’s assistants or surgeon’s assistants. Functioning under the direct supervision of a physician, NPPs can provide medical care and billable services.

Based on the Medicare fee schedule, medical practices can receive complete payment by successfully reporting NPP services which are “incident to” a physician’s care. However, CMS has complex and strict guidelines for incident-to medical billing and physicians need to understand these rules to bill correctly and receive full reimbursement for services provided by NPPs. Moreover, misapplying the conditions for incident-to billing can result in a fraudulent claim. Most physician practices prefer to rely on professional medical billing and coding services to resolve these challenges.

Here are the key points that physicians need to know about incident-to billing for an office visit:

  • According to the Healthcare Information and Management Systems Society (HIMSS), there is a lot of ambiguity about the term ‘supervising physician’. In its rule for CY 2016, CMS states that a “supervising” – or “billing” – physician does not have to be the ordering or original physician on the patient’s case. Under the incident-to rule, a credentialed physician must evaluate the patient to setup the plan of care; the NPP can perform follow-up visits which can be billed incident-to and provided based on a defined plan, though a supervising physician has to be the same suite. The supervising physician does not necessarily have to be the same physician who sets the plan of care. Incident-to services should be reported under the physician’s number who actually supervised the NPP’s service.
  • The provider under whose name the service is billed should remains involved in the care of the patient.
  • The physician must see established Medicare patients for their initial visits for new problems.
  • The service has to be provided in an office, and both the physician and NPP should be employees of the same entity.
  • The type of service must be that usually provided in physician’s offices or clinics, such as high volume, low acute services, including minor surgery, setting casts or simple fractures, reading X-rays, and so on.
  • While some states allow physicians’ assistants to practice under general supervision (where the physician is not required to physically be onsite when services are provided), this does not satisfy the Medicare direct supervision (physician onsite) requirement for incident-to billing.
  • The nurse practitioner cannot bill based on time when performing services “incident-to.” When counseling and/or coordination of care dominates (more than 50%) the face-to-face physician/patient encounter, Medicare specifies that time is the key factor in selecting the level of E&M service. However, face-to-face time refers to the time with the physician only.
  • CMS may reimburse services provided to hospital outpatients, and partial hospitalization services incident-to such services.

Incident-to services are coded using standard CPT, ICD, and HCPCS codes, without additional modifiers. When reported correctly, Medicare reimburses incident-to services performed by NPPs at 100 percent of the fee schedule amount. One important point to note when submitting claims is that commercial payers may have different rules from Medicare for incident-to billing. With all these complexities surrounding incident-to services reporting, partnering with an experienced medical billing and coding company is the ideal option to ensure higher reimbursement and avoid risks of noncompliance.