When (and When Not) to Follow Incident-to Guidelines

For Medicare patients in the physician office, services performed by a qualified non-physician practitioner (NPP) must meet incident-to guidelines. For a service to qualify as incident-to:

• The NPP must be licensed or certified to provide professional health care services in the state where the physician practice is located.

• In most cases, the NPP must be a full-time, part-time, or leased employee of the physician or physician group practice (in limited cases, the NPP may be an independent contractor).

• The NPP must provide services as an integral part of and incident-to the physician’s services.

• The NPP must provide such services under the direct supervision of the physician. Per Medicare rules, direct supervision means the supervising physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. The physician does not need to be present in the room during the procedure, but must not be performing another procedure that cannot be interrupted, and must not be so far away that he or she could not provide timely assistance. Documentation should substantiate the physician was present, on site, to supervise.

Incident-to rules do not apply to a hospital setting; rather, per Hospital Outpatient Prospective Payment System (OPPS) rules, therapeutic services in an outpatient setting may be provided under the direct supervision of an MD or DO; or, under the direct supervision of a physician assistant, nurse practitioner, clinical nurse specialist, certified nurse-midwife, licensed clinical social worker, or clinical psychologist who could personally furnish the service “in accordance with State law.” The supervising NPP must be privileged by the hospital to perform the services he or she supervises, and must abide by any applicable hospital physician-collaboration or supervision requirements.

Medicare physician supervision requirements do not apply to hospital inpatient services. Rather, CMS defers to hospital policy and Joint Commission (JC) standards for inpatient services.

Incident-to rules apply specifically only to Medicare payers. Private payers have their own rules and may, for instance, allow non-physician practitioners to treat new patients. Know your individual payers’ rules to be sure you report your NPP servicers optimally.

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