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Incident-to services

  1. Question Incident-to services
    Exam Training Packages
    We have just hired an APRN who will be seeing patients in our Coumadin Clinic as well as seeing established patient visits in the office setting. The Medicare enrollment process has not completed yet and, I can not remember if she can bill incident-to for follow-up office visits on Medicare patients, other than 99211. Can anyone advise if there are any code level restrictions for established office visits - or point me to a Medicare publication?
    It't either late on Friday or menopause....

  2. #2
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    Disclaimer
    This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other
    policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to
    review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
    Page 1 of 3
    Related Change Request #: N/A MLN Matters Number: SE0441
    Effective Date: N/A
    “Incident to” Services
    Note: This article was revised to contain Web addresses that conform to the new CMS web site and to
    show they are now MLN Matters articles. All other information remains the same.
    Provider Types Affected
    All Medicare providers of professional services
    Provider Action Needed
    None. This article is for your information only. It clarifies when and how to bill for services “incident to”
    professional services.
    Background
    The intent of this article is to clarify “incident to” services billed by physicians and non-physician
    practitioners to carriers. “Incident to” services are defined as those services that are furnished incident to
    physician professional services in the physician's office (whether located in a separate office suite or within
    an institution) or in a patient's home.
    These services are billed as Part B services to your carrier as if you personally provided them, and are paid
    under the physician fee schedule.
    Note: “Incident to” services are also relevant to services supervised by certain non-physician
    practitioners such as physician assistants, nurse practitioners, clinical nurse specialists, nurse
    midwives, or clinical psychologists. These services are subject to the same requirements as
    physician-supervised services. Remember that “incident services” supervised by non-physician
    practitioners are reimbursed at 85 percent of the physician fee schedule. For clarity's sake, this
    article will refer to “physician” services as inclusive of non-physician practitioners.
    To qualify as “incident to,” services must be part of your patient's normal course of treatment, during which
    a physician personally performed an initial service and remains actively involved in the course of
    treatment. You do not have to be physically present in the patient's treatment room while these services
    are provided, but you must provide direct supervision, that is, you must be present in the office suite to
    render assistance, if necessary. The patient record should document the essential requirements for
    incident to service.
    More specifically, these services must be all of the following:
    An integral part of the patient's treatment course;
    Related Change Request #: N/A MLN Matters Number: SE0441
    Disclaimer
    This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other
    policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to
    review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
    Page 2 of 3
    Commonly rendered without charge (included in your physician's bills
    Of a type commonly furnished in a physician's office or clinic (not in an institutional setting); and
    An expense to you.
    Examples of qualifying “incident to” services include cardiac rehabilitation, providing non-self-administrable
    drugs and other biologicals, and supplies usually furnished by the physician in the course of performing
    his/her services, e.g., gauze, ointments, bandages, and oxygen.
    The following paragraphs discuss the various care settings, which are important to note because the
    processes for billing vary somewhat depending on the care site.
    Your Office
    In your office, qualifying “incident to” services must be provided by a caregiver whom you directly
    supervise, and who represents a direct financial expense to you (such as a “W-2” or leased employee, or
    an independent contractor).
    You do not have to be physically present in the treatment room while the service is being provided, but you
    must be present in the immediate office suite to render assistance if needed. If you are a solo practitioner,
    you must directly supervise the care. If you are in a group, any physician member of the group may be
    present in the office to supervise.
    Hospital or SNF
    For inpatient or outpatient hospital services and services to residents in a Part A covered stay in a SNF the
    unbundling provision (1862 (a)(14) provides that payment for all services are made to the hospital or SNF
    by a Medicare intermediary (except for certain professional services personally performed by physicians
    and other allied health professionals). Therefore, incident to services are not separately billable to the
    carrier or payable under the physician fee schedule.
    Offices in Institutions
    In institutions including SNF, your office must be confined to a separately identifiable part of the facility and
    cannot be construed to extend throughout the entire facility. Your staff may provide service incident to your
    service in the office to outpatients, to patients who are not in a Medicare covered stay or in a Medicare
    certified part of a SNF. If your employee (or contractor) provides services outside of your “office” area,
    these services would not qualify as “incident to” unless you are physically present where the service is
    being provided. One exception is that certain chemotherapy “incident to” services are excluded from the
    bundled SNF payments and may be separately billable to the carrier.
    In Patients' Homes
    In general, you must be present in the patient's home for the service to qualify as an “incident to” service.
    There are some exceptions to this direct supervision requirement that apply to homebound patients in
    medically underserved areas where there are no available home health services only for certain limited
    services found in Pub 100-02, Chapter 15 Section 60.4 (B). In this instance, you need not be physically
    present in the home when the service is performed, although general supervision of the service is required.
    Related Change Request #: N/A MLN Matters Number: SE0441
    Disclaimer
    This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other
    policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to
    review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
    Page 3 of 3
    You must order the services, maintain contact with the nurse or other employee, and retain professional
    responsibility for the service. All other incident to requirements must be met. A second exception applies
    when the service at home is an individual or intermittent service performed by personnel meeting pertinent
    state requirements (e.g., nurse, technician, or physician extender), and is an integral part of the physician's
    services to the patient.
    Ambulance Service
    Neither ambulance services nor EMT services performed under your telephone supervision are billable as
    “incident to” services.
    Additional Information
    To provide additional clarity, we present the following scenarios:
    Must a supervising physician be physically present when flu shots, EKGs, Laboratory tests, or Xrays
    are performed in an office setting in order to be billed as “incident to” services?
    These services have their own statutory benefit categories and are subject to the rules applicable to their
    specific category. They are not "incident to" services and the "incident to" rules do not apply.
    Can anti-coagulation monitoring be provided “incident to” a physician's services in an office?
    Yes, if the requirements are met, i.e., the services are part of a course of treatment during which the
    physician personally performs the initial service and is actively involved in the course of treatment, is
    physically present in the immediate office when services are rendered by the employee, and the service
    represents an expense to the physician or other legal entity that bills for the service.
    If the treating physician (Doctor X) refers a patient to an anti-coagulation monitoring clinic, can
    Doctor X bill these services as “incident to?”
    No, because the services are not being provided by an employee under supervision of Doctor X.
    Can the supervising physician (Doctor Y) at the anti-coagulation monitoring clinic (a physician
    group) bill the services as “incident to” if Doctor Y directly supervises those services at the clinic?
    No, because Doctor Y is not treating the patient for the underlying condition. However, If Doctor Y
    receives a referral from Dr. X, and Dr. Y performs an initial evaluation of the patient and then orders and
    supervises the services, they may be billed by Doctor Y incident to her initial service.
    If you have further questions regarding this issue, please contact your carrier at their toll-free number,
    which may be found at
    http://www.cms.hhs.gov/MLNProducts/d...mDirectory.pdf on the CMS web
    site.
    Chastity Nault, CPC
    HIM Professional Services Coder - Remote

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