Incident-to Guidelines, Quickly

Incident-to Guidelines, Quickly

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 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.

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.
John Verhovshek

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About Has 605 Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

2 Responses to “Incident-to Guidelines, Quickly”

  1. Giovannina Rondinella says:

    To which cpt 4 e/m codes apply to incident to

  2. Angie Green says:

    Please clarify: Can a NP see an established patient in the office without the ordering doctor being in the building, however one of the other doctors in the practice is physically in the building, can the NP bill incident-to under the ordering doctor or does she have to bill incident-to under the doctor that is physically in the building?

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