“Incident to” is a Medicare billing provision that allows services provided by a non-physician practitioner (NPP) in an office setting to be reimbursed at 100 percent of the physician fee schedule by billing with the physician’s NPI. According to the Medicare Benefit Policy Manual “incident to”, is defined, in part, as “services furnished as an integral although incidental part of a physician’s personal professional service.” To bill Medicare “incident to” for services provided by an NPP the following criteria must be met:
• The service performed should be within the scope of practice of the NPP and in accordance with state law.
• The physician must personally treat the patient on the patient’s first visit to the practice or treat any established patient who comes to the office with a new medical condition. NPPs may provide follow-up care.
• The physician must be in the suite of offices (on-site) when the NPP is rendering the service.
It is important to remember that the physician must continue to see the patient at a frequency that reflects ongoing management of the patient’s care as defined by state law.
INCIDENT TO’ BILLING CLARIFICATION
Louisiana Medicaid issues the following clarification for billing services as ‘incident to’ a physician’s professional service.
• ‘Incident to’ a physician’s professional services means that the services or supplies 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. This means that the physician, under whose provider number a service is billed, must perform or be involved with a portion of the service billed. Physician involvement may take the form of personal participation in the service or may consist of direct personal supervision coupled with review and approval of the service notes at a future point in time.
• Please note that direct personal supervision by the physician must be provided when the billed service is performed by auxiliary personnel. Direct personal supervision in an office means the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the service is performed.
• In addition to services performed by non-physicians, such as nurses or aides, services performed by other non-physicians whose licenses allow them to perform physician-type services (Nurse Practitioners, Physician Assistants, and others) may qualify as ‘Incident to’ a physician’s service. However, it is important to remember that, even if the physician supervision requirements are met, the service does not qualify as ‘Incident to’ unless the physician performs or is involved with some portion of the service billed.
• In situations where non-physicians such as an NP or PA provides all parts of the service independent of a supervising physician’s involvement, the service does not meet the requirements of ‘Incident to’ billing. Instead, the service must be illed using the provider number of the non-physician practitioner and must meet the specific coverage requirements of the practitioner’s scope of practice.
Provider Alert
It has come to the Department’s attention that some physicians have attempted to bill for services rendered within the scope of practice of associated non-physician providers such as the NP or PA as though ‘incident to’ the physician’s services. Supervision and ‘signing off’ of records does not constitute ‘incident to’. Services billed in this manner are subject to post payment review, recoupment, and additional sanctions as deemed appropriate by the Department.
What other requirements must be met before an NPP may bill under Medicare’s “incident to” provision?
• The NPP must be a W-2 or leased employees of the physician, and the physician must be able to terminate the employee and direct how the Medicare services are provided by that employee.
• The initial visit (for that condition) must be performed by the physician .This does not mean that on each occasion of an incidental service performed by an NPP, that the patient must also see the physician. It does mean, however, that there must have been a direct, personal, professional service
furnished by the physician to initiate the course of treatment of which the services being performed by the NPP is an incidental part.
• There must be direct personal supervision by the physician as an integral part of the physician’s personal in-office service. The physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary;
• The physician has an active part in the ongoing care of the patient. Subsequent services by the physician must be of a frequency that reflects his/her continuing active participation in, and management of, the course of the treatment.
To be considered an employee for purposes of the “incident to” provision, the NPP performing an “incident to” service may be a:
• Part-time;
• Full-time; or,
• Leased employee of the supervising physician, physician group practice, or of the legal entity that employs the physician who provides direct personal supervision.
No. By definition, a practice cannot bill a new patient visit or for a new condition performed by a PA or NP under the supervising physician NPI number as “incident to.”
Incident to: This term means services that are:
1. furnished as an integral, although incidental, part of a physician’s personal professional services;
2. performed under the physician’s direct supervision;
3. performed by qualified therapists or other qualified auxiliary personnel who are employees of the physician (as defined above); and
4. furnished during a course of treatment where the physician performs an initial direct, personal, professional service and performs subsequent services at a frequency that reflects his/her continuing active participation in and management of the course of treatment.
5. The services of a PTA or OTA shall not be billed as services incident to a physician/NPP’s service, because they do not meet the qualifications of a therapist.
