The Basics of Medicare’s “Incident To” Billing Rules

 “Incident To” billing is a Medicare concept that permits physicians and non-physician practitioners (“NPP”) that are not credentialed with Medicare to bill Medicare and be paid for their services – in certain circumstances. 

Common Scenarios for “Incident To Billing”:

 

  • Because nurse practitioners are allowed only 85% of the Medicare fee schedule, the practice elects not to credential the nurse practitioner with Medicare. Instead, the nurse practitioner bills for her services under the supervising physician’s NPI pursuant to “Incident to” billing and is allowed 100% of the Medicare fee schedule.

  • A new physician or non-physician practitioner joins the practice but is not yet credentialed with Medicare. The new physician sees patients but the claims are billed under the supervising physician’s NPI pursuant to “Incident to” billing.

               Note: There is a good amount of debate in the billing community as to whether the second scenario is a legitimate and permissible use of “incident to” billing. For a more in depth discussion of this issue, please see our upcoming article “Can a physician use “Incident To” billing while waiting for credentialing approval?”

Official Medicare Requirements for “Incident To” Billing

 

According to Chapter 15, Section 60 of the Medicare Benefit Policy Manual, “Incident to” services are those performed by a non-credentialed physician or that are:

1. an integral, although incidental, part of the physician’s professional service;

2. commonly rendered without charge or included in the physician’s bill;

3. of a type that are commonly furnished in physician’s offices or clinics;

4. furnished by the physician or by auxiliary personnel under the physician’s direct supervision.

What Medicare’s Requirements Mean for Most Medical Practices

 

In more practical terms, this means the following:

1. The medical services must be consistent with and incidental to a Plan of Care established by a credentialed physician.

2. The services must be rendered in a physician’s office or clinic; “incident to” billing is not available for in-patient or skilled nursing facility care. 

3. The services must be directly supervised by the supervising physician. The supervising physician need not be in the same room, but must be in the same office suite; being available by phone is not sufficient. 

Some Important Facts about “Incident To” Billing.

 

1.  Can I use “Incident To” billing for a New Patient Visit?

No. “Incident to” billing is not permissible for an initial patient visit, routine physical exams, or even for subsequent patient visits where a new Plan of Care is established.  “Incident to” billing is available only to implement a pre-existing Plan of Care established by a credentialed physician in that same practice.

2.  Can a Physician supervise another physician under “Incident To” billing?

Yes.  Again, this is the subject of some debate within the billing community, and some have taken the position that physicians may not supervise other physicians. However, Medicare has explicitly stated that physicians may supervise other physicians for “incident to” billing. See Federal Register, Vol. 66, No. 212, page 55268.

3. Can I use “incident to” billing to administer vaccines or diagnostic tests?

Yes, but you don’t have to.  Medicare has established specific supervisor and administration rules for certain categories of medical services, including diagnostic tests and vaccine administration. For example, non-physician practitioners may administer vaccines without physician supervision. As long as the provision of service complies with those category-specific requirements, the service need not also comply with the terms of “incident to” billing.

4. Can I use “incident to” billing in an inpatient or skilled nursing facility (SNF)?

No. If the patient is in a Medicare-covered inpatient or SNF stay, “incident to” billing is not permissible. SeeMedicare Benefit Policy Manual, Chapter 15, Section 60.1.

5. Can I use “incident to” billing in an outpatient hospital setting?

Yes, as long as all other requirements of “incident to” billing are met.  The requirement that the supervising physician by in the same office suite is often the problem in outpatient settings.

6. Can a credentialed Non-physician practitioner supervise another medical practitioner?

Yes, but only if she can do so in compliance with all other applicable state laws and regulations. For example, because state laws generally prohibit a nurse practitioner from supervising a physician, she is prohibited from supervising a physician for purposes of “incident to” billing.

7. How Should I Document Compliance with “Incident to” Billing?

A co-signature on the medical notes by the supervising physician is not sufficient to establish proper documentation.  Your medical notes should include at least the following:

  • The names of both the rendering provider and the supervising provider;

  • That the supervising provider was physically in the office and available to participate in the medical services if needed;

  • That the medical services provided were consistent with an existing Plan of Care established by the supervising physician;

  • Since “incident to” billing requires that the supervising physician remains responsible for the Plan of Care, the supervising physician should see the patient frequently enough to stay involved in the provision of care; the medical notes for the patient should reflect the supervising physician’s continued involvement in the patient’s care.

Summary

 

Medicare’s “incident to” billing rules can help provide high-quality medical care while protecting the financial performance of the practice. However, while the guidelines are not complicated, they do require some advance planning and supervision.

These rules can also be helpful in dealing with commercial carriers. In our experience, most commercial carriers do not publish their requirements for properly supervising other medical providers. In the absence of clear guidelines from a commercial carrier, we believe that following Medicare’s “incident to” guidelines can go a long way towards achieving the real goal in these cases – providing high-quality and effective medical care for all patients.

 

Rusty Wilson is the founder and principal of eMed Partners, a full-service medical billing company for physicians and medical practices.

For more about our billing services: http://emedpartners.com/

To follow me on LinkedIn: https://www.linkedin.com/in/rusty-wilson-520206/

Mike Moll