Services and supplies properly provided and billed incident-to a physician’s or non-physician practitioner’s services are reimbursed at 100 percent of the Medicare fee schedule amount for Medicare beneficiaries. This provides an opportunity for practices to make the most of their auxiliary staff—but only if they adhere to the Center for Medicare & Medicaid Services’ (CMS) strict incident to requirements. The following quick tips help you cover the basics.
The patient must be established, with an established problem or complaint
Per the Medicare Benefits Manual, Chapter 15, Section 60.1, incident to services “are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.”
Practically speaking, this means the physician or qualified NPP must have seen the patient previously for the problem or complaint for which the incident to service was provided. New patients, or those with a new problem, cannot be seen incident to.
The physician does not have to provide a personal professional service each time the patient is seen incident to, but neither can the physician “turn over” care of the patient to auxiliary staff. He or she must remain directly involved with the patient’s care, or—as the Benefits Manual states—“there must be subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment.”
Services must be medically necessary and appropriate in the physician office
The Benefits Manual states it this way: “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.”
Direct supervision is required
Incident to coverage “is limited to situations in which there is direct physician supervision of auxiliary personnel,” per the Benefits Manual. Direct supervision means the physician must be present in the office suite and immediately available to provide assistance and direction. The incident to service should be billed in the supervision physician’s name.
Auxiliary personnel means any individual who is acting under the supervision of a physician, “regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician.”