Defining ‘Incident to’
‘Incident-to’ services are usually initiated by a physician and provided by a non-physician provider (NPP) following the care plan and supervision of the physician. The physician must be physically present in the office suite and the services provided must be commonly performed in the physician’s office. If the criteria are met, the service should be billed under the physician’s national provider number (NPI) and the practice receives 100 percent of the physician’s fee schedule for the service. Note that, incident-to services are only applicable to Medicare. Incident-to services are only applicable for charges billed to a Medicare contractor. You will have to verify with each private insurance carrier on how to bill for services performed by an NPP.
Billing Requirements for ‘Incident-to’ Services
- As discussed above, incident-to billing applies only to Medicare; and, the incident-to billing does not apply to services with their own benefit category. Diagnostic tests, for example, are subject to their own coverage requirements.
- The service billed incident to must take place in a ‘noninstitutional setting,’ which the Centers for Medicare & Medicaid Services (CMS) defines as ‘all settings other than a hospital or skilled nursing facility.’ Hospital services incident to physician’s or other practitioner’s services rendered to outpatients (including drugs and biologicals which are not usually self-administered by the patient), and partial hospitalization services incident to such services may also be covered.
- Incident to services cannot be rendered on the patient’s first visit, or if a change to the plan of care occurs. A Medicare-credentialed physician must initiate the patient’s care. If the patient has a new or worsened complaint, a physician must conduct an initial evaluation and management (E/M) service for that complaint and must establish the diagnosis and plan of care.
- Subsequent to the encounter during which the physician establishes at a diagnosis and initiates the plan of care, an NPP may provide follow-up care under the ‘direct supervision’ of a qualified provider.
- A physician must ‘actively’ participate in and manage the patient’s course of treatment. This requirement typically is defined by individual state licensure rules for physician supervision of NPPs.
- Both the credentialed physician and the qualified NPP providing the incident to service must be employed by the group entity billing for the service. If the physician is a sole practitioner, the physician must employ the NPP.
- The incident to service must be of a type usually performed in the office setting and must be part of the normal course of treatment of a diagnosis or illness.
Billing Basics for ‘Incident-to’ Services
- Eligible NPP: An NPP is a non-physician provider who must meet supervision requirements in order to provide ‘incident to’ services and to receive appropriate compensation for the physician. NPPS can be a physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), or advanced practice registered nurse (APRN), etc., and their scope of practice as defined under state law must allow providing ‘incident to’ services
- New patient: A patient new to the office would not have been seen by the physician, and consequently there wouldn’t be a physician-initiated plan of care. The patient would not be under the physician’s supervision. So, if the NPP evaluates and treats the new patient without an initial visit with the physician, then he or she will have to bill the services under their NPI number and receive reimbursement at 85 percent of the physician fee schedule.
- Established Patient: The NPP would not be able to bill established patient, this as incident-to. The new complaint would not be in the physician’s plan of care and so it would not meet the criteria for being billable as an incident to service. The NPP could address the patient’s new problem but they would need to bill under their own NPI and receive 85 percent of the physician’s fee schedule rate.
- Direct supervision means the physician must be in the office suite and can immediately be available to provide assistance if needed.
- Shared/split visit: A shared/split visit is when both the physician and the NPP share a visit in treating the patient. This is now allowed for outpatient services such as office visits. Both the physician and NPP must independently document their part of the visit. For example, an established patient presents with a new problem along with an established problem and is being seen by the NPP. The NPP can call in the physician to assess the new problem but the documentation must include the NPP’s assessment of the established problem, and the physician must document the assessment of the new problem separately.
Accurate billing and coding backup by proper documentation will reimburse all your ‘Incident-to’ services. Most of the time, practice owners are unaware of different billing scenarios in ‘Incident-to’ services and end up receiving claim denials. Medisys Data Solutions can assist you in medical billing for your rheumatology practice including ‘Incident-to’ services. Our expert medical billers and coders are well versed with billing guidelines and billing scenarios and ensure accurate insurance reimbursements for delivered services. To know more about our rheumatology billing and coding services, contact us at info@medisysdata.com / 302-261-9187
