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Incident-to ServicesIncident-to billing refers to billing outpatient services that are performed in a physician’s office located in a separate office, institution, or in a patient’s home. These services are often provided by a non-physician practitioner (NPP) such as a nurse practitioner (NP), physician assistant (PA), or other non-physician provider. Incident-to services include administering injections, taking vital signs, changing dressings and removing sutures. When a physician assistant or a NP supervises, the services are billed under the PA’s or NP’s NPI and reimbursed at 85% of the physician fee schedule.

Since this billing process can be rather confusing, it is important to understand clearly how incident-to billing works.

NPPs can provide services without direct physician supervision and can bill directly for the provided services, and as incident-to a physician’s services if they are licensed by their state to assist in providing the services.

Billing under a Physician’s NPI (National Provider Identifier)

NPPs providing services that are incident-to a physician or other practitioner’s service can bill under the physician’s NPI provided the service is:

  • An integral, though incidental part of the physician’s professional service.
  • Of the kind that is commonly furnished in physician clinics and offices.
  • Usually rendered without charge or included in the physician’s bill.
  • Provided by the physician or auxiliary personnel under the physician’s direct supervision.

There should have been a direct, professional service provided by the physician to start the course of treatment, of which the service being performed by the non-physician is an incidental part. The physician must see the patient first, to start the plan of care for that patient, after which the NPP follows that plan of care during subsequent visits. An important thing to note is that if a patient mentions a new problem during a follow-up visit for a problem with an established plan of care, that visit cannot be billed as incident-to. Such a visit should be billed as the appropriate new or established service under the NPP’s own provider number. In this case, the physician should have performed the initial service for the diagnosis or condition and remain actively involved during the entire treatment course. The physician must also perform subsequent services to prove his continued active involvement in the patient’s care.

Direct Supervision

The term direct physician supervision in the office setting signifies, according to CMS, that the physician is present in the office and is immediately available and able to provide assistance and direction throughout the time the service is performed. It doesn’t necessarily mean that the physician must be present in the same room. Any service conducted outside the office setting, such as the patient’s home, institution other than a hospital, or Skilled Nursing Facility, can be classified as incident to a physician’s service only when there is direct personal supervision by the physician.

An NPP or other auxiliary staff member can bill a service under a physician’s NPI only when a physician is in the office and directly available to help, if it is needed. The physician providing the direct supervision or one who is in the office need not be the physician that established the plan of care for the patient.

While many services and supplies are covered incident-to in an office setting when provided by an NP, the physician cannot bill for them when provided in hospital settings. Simply put, if the physician uses the services of his own employees in a hospital setting and merely supervises the services, he is not eligible for Medicare payment. In a hospital setting, the physician is not entitled to practitioner payment if he does not personally perform the service.

General Supervision

General supervision requirements apply with regard to service provided to homebound patients (patients whose ability to leave home is restricted and requires considerable effort) in underserved areas. General supervision requires the physician to be physically present at the patient’s place of residence when the service is performed. The service must be ordered by the physician and performed under his overall supervision and control. The physician retains professional liability for the service.

It is important to follow the guidelines, though complex, of incident-to billing very closely because this is a billing area that is minutely scrutinized by payers who recognize this billing technique.