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Thread: Billing for PA's and incident to billing.... Medicare

  1. #1

    Default Billing for PA's and incident to billing.... Medicare

    AAPC: Back to School
    I have a few different issues....

    1. We have a PA that is credentialed through Medicare. Can we bill with her as the billable provider or must it be billed as incident to???

    2. We have a NP that is not credentialed through Medicare and we do need to bill as incident to. How do we bill that? Must the physician sign off on the chart notes? Incident to billing is very confusing to me and I am not sure how the HCFA is suppose look??? For example, box 24 J should list the rendering provider, box 31 list who???

    Any input would be greatly appreciated. I have read CMS guidelines and it is all just a bit confusing for me.

    Tabitha CPC
    Last edited by tgesmundo; 09-25-2009 at 01:23 PM.

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    CR 148 issued April of 2004 states how to bill an incident t0 claim, it must meet the definition of incident to in the it is a followup encounter while the physician is on site. Then you will put the physician name and NPI of the physician in this practice that saw the patient for the same dx and ordered the follow up encounter, then in 24J you put the NPI of the physician that is on site supervising (any physician in the practice with the same specialty) and the 24J will match line 31.
    If the PA is credentialed then you may bill under his/her number, and incident to only when the definition has been met.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3


    For the PA, you can bill direct under the PA's NPI number or incident-to, under the MD's NPI number, if the incident-to guidelines are met. If you bill direct, under the PA, Medicare will allow 85% of the fee schedule amount. If you bill incident-to, under the doctor, Medicare will allow 100% of the fee schedule amount.

    For the NP, you will need to submit incident-to.

    Incident-to guidelines are as follows: the non-physician provider (NPP) can only see established patients with established problems. The idea is that the physician has already set up a treatment plan and the patient is just coming in for follow-up. Therefore, a new patient could not be billed incident-to and an established patient with a new problem, could not be billed incident-to (for example, if an established patient came in with an established problem of HTN but now he has abdominal pain, the physician would have to actually see the patient to treat the abd pain. The NPP could not just treat it).

    In order to bill incident-to, the physician must be in the office suite during the visit with the NPP. The physician does not need to see the patient nor document a note in the chart but he/she must be in the office.

    I'm not sure why you mentioned box 24J on the HCFA, that box is for COB info. The provider you're billing under, whether its the NPP or the physician, should be listed in Box 31 (so, if billing incident-to, list the physician in box 31). I think I saw a link to CMS guidelines about incident-to billing somewhere on these forums. If I can find it, I will post it for you.

    Incident-to is confusing. Let me know if you have questions. Feel free to email me directly if you want or posting here is fine too.

    Lisi, CPC

  4. #4
    Join Date
    Apr 2007


    This is how we have always done it. If a PA or NP is credentialed with Medicare and service provided is not incident to we bill with the PA's or NP's number and info in block 33. If they are credentialed and they provide incident to we bill under MD because even though they are credentialed you can still bill incident to under the MD's number and reimbursement is higher. In that situation we have the MD's info in block 33 and the PA or NP's name and NPI in 24J. Hope this helps and it has worked for us!

  5. #5
    Join Date
    Apr 2007
    Columbia, MO


    As I stated you need to look at CR148 which was released in 2004 it states exactly how the incident -to claims are to be submitted, unless there has been something more recent released, and if so I would appreciate the reference, but as far as I know that was the last transmittal on the submission of an incident-to claim.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6

    Default Question about incident to for a pa

    Does this vary from state to state. I know a md in California that insists that everything be billed to the

  7. #7


    [QUOTE=CaryGreenberg;190500]Does this vary from state to state. I know a md in California that insists that everything be billed to the physician?

  8. #8
    Join Date
    Apr 2007
    Columbia, MO


    no it does not vary state to state. it is in the Medicare policy manual sec 2050

    Debra A. Mitchell, MSPH, CPC-H

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