Understanding Incident-to Services
By: Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO
Most practices use incident-to services at some time or other, whether it is an encounter where a nurse or medical assistant just takes a blood pressure or gives an injection, or it can expand all of the way to a Non Physician Practitioner (NP, PA, etc) providing a full evaluation and management (E/M) service in the office but you are billing it under a physician’s ID.
What makes a service incident-to is that someone other than the supervising physician is providing the service, but the service is billed out under the supervising physician’s NPI. The actual provider of the service, the nurse, medical assistant (NPP) is invisible to the payer on the claim. There is no modifier to indicate that a service is being provided incident-to, so the claims all appear as if the physician whose NPI was used was the provider who provided the services.
Medicare has very specific rules as to when you can use incident-to and how to bill under a supervising physician’s NPI. However, non-Medicare payers do not present their rules in a clear and forthright manner as you find with Medicare. This means that I would not recommend that practices assume that non-Medicare payers follow Medicare’s rules without finding out from each of your payers specifically and asking them for their rules for billing incident-to services in writing.
Let’s look at Medicare’s rules, which are found in the Internet Only Manual (IOM) in Chapter 12 of Publication 4, in section 30.6.4: Evaluation and Management (E/M) Services Furnished Incident to Physician’s Service by Nonphysician Practitioners (Page 49) and in Chapter 15 of Publication 2: 50.3-Incident To Requirements ( Page 56).
The parameters to bill an incident-to service under the supervising physician is specifically listed in the second link provided above, in Chapter 15 of Publication 2 of the Medicare Internet Only Manual, Page 56. When these specific rules are not followed, the practice is considered to be committing abuse or potentially even fraud by regulating bodies and they take this very seriously. I have been involved in a quite a few cases as an expert witness, both trying to defend the provider as well as on the prosecuting side, unfortunately. Practices that are prosecuted for violation of these rules have usually been told that they are violating the rules and requested to change their operating procedures. The prosecution ends up as a result of the organizations not responding to these requests and continuing to violate the very specific Medicare rules.
In order to bill under the supervising physician’s NPI, the service must:
- Be part of the physician’s plan of care for the patient.
- The supervising physician must be on site, providing “direct supervision” in the office suite while the service is rendered by the incident to personnel.
- The Incident To personnel must either be a W-2 or contracted employee.
This means that incident-to cannot be billed for a NPP seeing a new patient or a new problem where there is no plan of care for an established patient and bill it incident-to. The NPP can bill the above services under their own NPI and the practice will be allowed 85 percent of the Medicare fee schedule.
It also means that the physician’s NPI that is used must represent a doctor that is ON SITE, in the office suite at the time of the incident-to services. The doctor whose NPI is used does not have to be the patient’s doctor, does not have to be the doctor who established the plan of care and does not have to be the doctor who ordered the service. But the doctor whose NPI is used does have to be the doctor who was on site with the nurse, MA or NPP when the service was rendered. Using the NPI of another doctor in the group, who was not in the office suite, who may have been doing surgery, was in another office or was off that day is considered “billing for services not rendered” because that doctor was not on site and did not supervise the incident-to services.
So, please take away the following:
Incident-to billing to Medicare is OK if:
- There is a plan of care for the patient for what is being treated
- The NPI being billed is the NPI of the physician who is ON SITE when the incident-to service is performed
- It would be smart for the incident-to personnel to document at the beginning of their note: “Doctor A in office supervising today” so that when and if the incident-to services are audited, the note has documentation that the billed doctor, Doctor A was on site.
- For Non-Medicare, inquire from each payer and get from them, in writing what their rules are for billing incident-to as well as for billing for NPP services.