Incident To

Recognizing Non-physician Practitioners for Payment Purposes Requires Attention to Detail.

By Robert A. Pelaia, Esq., CPC

Non-physician practitioners, such as physician assistants and advanced registered nurse practitioners, are becoming more and more of a presence throughout the healthcare industry. These non-physician practitioners are permitted to bill the Medicare program under their own provider numbers and Medicare will reimburse them at 85 percent of the physician fee schedule. That is the easy way to bill.

Another way the Medicare program recognizes non-physician practitioners for payment purposes is by reimbursing physicians for services provided by non-physicians as “incident to” the physician’s care. However, the Medicare incident to rules are routinely misunderstood and frequently cause problems for physician practices that do not pay enough attention to detail.

You cannot afford to make mistakes when billing incident to. Indeed, the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) frequently identifies incident-to services as an area of intense focus in its annual work plans. A study to review the performance of incident to services was included in the OIG’s 2004 work plan. Then the issue dropped off the work plan for 2005 and 2006, but it re-appeared on the OIG’s 2007 work plan and remains in the 2008 work plan as follows:

Medicare “Incident to” Services

We will review Medicare claims for services furnished “incident to” the professional services of selected physicians. Medicare Part B generally pays for services incident to a physician’s professional service; such services are typically performed by a non physician staff member in the physician’s office. Federal regulations at 42 CFR § 410.26(b) specify criteria for incident to services. We will examine the Medicare services that selected physicians bill incident to their professional services and the qualifications and appropriateness of the staff who perform them. This study will review medical necessity, documentation, and quality of care for incident to services.

It would be impossible to provide a comprehensive review of all of the details of the incident to requirements in this brief article and I assume you have a grasp on the basics of incident to billing. However, there are many lesser-thought-about nuances that have the potential to cause compliance problems for practice administrators who might not be paying attention to details.

Pay Attention to Details

Incident to billing allows the physician to be paid for services provided by staff, but it also carries significant compliance risks. A few often overlooked but important nuances to keep in mind include the following:

  • If the physician is in a group practice, any group practice member can supervise the incident to service.
  • The physician who initiated the plan of care does not need to be present during the incident to service provided that another physician member of the group is present in the office suite.
  • The incident to concept does not apply in a hospital or skilled nursing facility setting.
  • Incident to services can be provided by the physician’s “auxiliary personnel.” Auxiliary personnel can be employees, leased employees, or independent contractors of:
  • Ÿ The physician, or Ÿthe entity that employs or contracts with the physician (for example, a clinic)
  • There must be direct physician supervision at every visit.
  • Direct supervision in an office setting means that the physician is present in the office suite and immediately available to provide assistance and direction while the auxiliary personnel are providing services.
  • ŸThe physician is not “in the office suite” if he or she is on the way to the office from home, seeing patients in another office across town, making rounds in the hospital across the street or vacationing in Paris.
  • Avoid using incident to as a means of getting payment for services provided by a physician who is not credentialed. In other words, you should never bill one physician as incident to another physician’s service.
  • The physician must perform an initial service and must actively participate in and manage the course of treatment.
  • Ÿ The physician does not need to see the patient on every visit, as long as the physician has prescribed the plan of care and is actively managing the plan of care.
  • ŸThe non-physician practitioner cannot see new patients or established patients with new problems on an incident to basis.
  • Ÿ It is vital that someone is keeping track of physician involvement and that you can prove physician involvement on an “active” level.
  • The non-physician practitioner can provide any service on an incident to basis that he or she is otherwise authorized to perform under state scope of practice laws.
  • If an evaluation and management service is provided on an incident to basis by a non-physician practitioner, the physician can bill for whatever established patient evaluation and management (E/M) level that is documented and medically necessary.
  • If an E/M service is provided on an incident to basis by auxiliary personnel who are not non-physician practitioners, only a Level 1 visit (99211) can be billed regardless of extent of documentation or length of visit.
  • When a non-physician practitioner is managing the patient’s care, auxiliary personnel can provide services incident to the non-physician practitioner’s service.
  • Ÿ The incident to service must be performed under the non-physician practitioner’s direct supervision.
  • Ÿ The service is billed under the non-physician practitioner’s provider number.

Biller Beware

It is important to note that incident to billing carries a higher risk of non-compliance because it is completely transparent to the payer. When a claim for an incident to service performed by a non-physician practitioner is received for reimbursement, it looks just like a claim for a physician service. It is likely that providers will be paid for the claim even if you have not complied 100 percent with the incident to requirements on your end. The bill and explanation of benefit (EOB) received by the patient look suspicious because the patient sees that they were billed for a doctor visit, yet they know that they did not see the doctor that day. This perceived inconsistency might prompt calls to various fraud hotlines. You need to be certain that you have the appropriate documentation to back up your claim if you are ever audited.

While incident to billing can bring increased revenue; it comes with a long list of compliance concerns. However, these concerns do not present insurmountable hurdles. All you need to do is take the time to ensure that you have a firm grasp on the requirements and that someone is periodically reviewing your claims for compliance.

Information published in this article is the personal views of the author and not that of the University of Florida. Information published in this article is not intended to be, nor should it be considered, legal advice. Readers should consult with an attorney to discuss specific situations in further detail. Mr. Pelaia gratefully acknowledges Ms. Maryann Palmeter, CPC, for her valuable assistance with editing this article.



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