3 Tips Guide Successful Incident-to Billing

March 1st, 2013

Doctor with laptopServices 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.”


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20 Responses to 3 Tips Guide Successful Incident-to Billing

  1. PAT Says:

    INCIDENT TO

  2. jennifee Says:

    Can incident to be used when a new md starts w a speciality practice and not yet be credentialed under that ins yet. There fore using another md name as supervising??

  3. deb Says:

    I would like to know the ans. to jennifee ? also

  4. Nancy Says:

    Can provider based practices, POS 22, bill incident to professional (not facility) services provided by a nurse, supervised by a provider?

  5. Karen Bartrom, CPC, CEDC, CEMC Says:

    My understanding is that “incident-to” guidelines do not apply to Provider Based Clinics.

  6. silvia foote Says:

    Where can I search for documentation guidelines for a respiratory therapy initiation and management of cpap machine?
    Thank you,

  7. Barb Says:

    Please clarify “incident-to” guidelines for Hospital care Consults, When a NPP or PAC write most of a new consult and Phys oversees the notes and coments, if majority of consult written is by NPP or PAC we bill under the NPP or PAC, not the physician. Is this correct?

  8. TAT Says:

    Ensure that the attending physician has signed an agreement for the business and with the physician assistant PA or NPP can use his or her Medicare for billing regarding the incident to guidelines.If a new physician is on board whom has not completed their Medicare credentialing process he or she CANNOT use the attending doctor’s Medicare number for billing. Medicare will let you back bill for the new physician’s old services once he or she becomes credentialied properly in the Medicare network. However, if the doc does not have their medical speciality boards completed then this slows the process of credentialing with Medicare

  9. Cindy Says:

    Would incident to guidelines apply to cardiac rehab services in a hospital OP place of service? I have a practice that wants to bill for these services but the physician in not physically present in the rehab center. He is available three floors up in the clinic/office suite
    Thanks for any insight you can give on this

  10. Donna Says:

    Can a PA bill incident to in a hospital setting? Our docs round at local hospitals and want to use the PA in that setting. Also, what is the take on therapists (LCSWs) in a psych setting? I am very clear on the Medicare incident to guidelines–does anyone know the answers to these questions for the commercial payors?

    Thanks!

  11. Barbara Pardue, RN, CPC Says:

    Incident-to guidelines: CMS Medicare Benefit Policy Manual, chapter 15, sections 60-60.3
    NO “incident to” services “in facilities.”

  12. Jetton Torix CCS-P Says:

    You are not allowed to bill any physician to any other physician.

  13. joel evans Says:

    does a session with a non-credentialed unlicensed medical assistant qualify for incident to billing for nutritional and lifestyle education based on a plan designed by a physician?

  14. Angela S Says:

    to answer Jennifee’s question, incident to does not apply to physicians acting under another physician. A doctor cannot EVER bill under another doctor’s name. The incident to rules are designed to allow the physician to be reimbursed at the full participating rate when a service is provided by a non-physician practitioner (CNP, CNM, PA, CNS, etc…) whom he/she employs/contracts. This is why there are strict guidelines that must be followed in order to bill a service “incident to”. The supervising/directing physician must be in suite at the time the service is rendered, the physician must provide the initial service and establish the plan of care, and must also be continuously involved in the plan of care. For example, if a primary care doctor has a patient with diabetes, the PCP must provide the initial service related to diabetes and must document the diagnosis and plan. The patient can follow-up with a CNP for the diabetes and bill for those follow-up visits under the supervising physician’s name. Your MAC may have specific guidelines on how to substantiate “continuous involvement” but generally as long as the doctor reviews each note and signs off AND sees the patient from time-to-time, that should suffice.
    Now, if that same patient comes in with a new complaint like a yeast infection or URI and sees the CNP, the service must be billed under the CNPs name. These are new complaints that are being assessed by the CNP.
    Also, keep in mind that some services are not subject to “incident to” rules like 99211, vaccines, EKGs, etc… Those services can be billed under the physician’s name without meeting all of the incident to requirements.

  15. Jo Says:

    Do Genetic Counselors fall under “incident to” guidelines?

  16. kelly Says:

    Is a co-signature by an MD required to bill an incident to service provded by a PA?

  17. Eddouja MD Says:

    In rural area , is it true that you can bill incident to even when the physician is not in the suite or facility?

    If a patient was seen initially by PA , then on second or third visit by. MD after the MD encounter can we use “incident to” for subsequent visits?

  18. Jennifer Says:

    If a RN provides pre-immunization counseling prior to giving an immunization to an established pediatric patient, can that counseling service be billed under the primary care physician’s name?

  19. Elaine.agonoy@nhcare.org Says:

    Can a registered dietician bill under a CNM for Diabetic Self Management service?

  20. Danielle Says:

    Our billing is done at another site. What documentation is needed or lets the “biller” know to bill incident to. Rigght now we send via email a list of patients from the CNP to bill incident to. However, at a former practice we never did this. Our biller was off site an knew to bill that way. What is needed to flag the biller to bill incident to???

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