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Incident To-Question

  1. Cool Incident Too
    Medical Coding Books
    Thank you AAPC for making it more clearer on the "Incident Too" ruling. Do you have any information from CMS re: ruling change to allow any provider within the group or any provider can be on site on the claim.

    Belinda Vargas
    Last edited by k205412; 01-04-2008 at 07:41 AM. Reason: signature

  2. Default incident-to
    Medicare B New Issue 214 August 25, 2004

    Related Change Request (CR) #: 3242 Medlearn Matters Number: MM3242

    Related CR Release Date: June 18, 2004

    Related CR Transmittal #: 17

    Effective Date: October 4, 2004

    Implementation Date: October 4, 2004

    Instructions for Providing Supervisor's Information When a Service Incident to the Ordering Physician Is Supervised by Another Physician in the Group

    Provider Types Affected

    Physicians and non-physician practitioners

    Provider Action Needed

    Physicians and non-physician practitioners should note that this instruction clarifies that the supervisor's identification is required on a claim when a service performed incident to the service of one physician or non-physician practitioner is supervised by another member of the same group. It instructs how to report ordering physician and supervising physician information on the electronic claim form.


    The preamble of the proposed rule for the Medicare Physician Fee Schedule on November 1, 2001 (66 Fed Reg. 55267) stated: "The billing number of the ordering physician (or other practitioner) should not be used if that person did not directly supervise the auxiliary personnel."

    This rule was included by the Centers for Medicare & Medicaid Services (CMS) to give instructions for providing the supervisor's information on the CMS paper claim form (CMS-1500). Details regarding how to complete the paper claim form 1500 can be found in the Medicare Claims Processing Manual, Publication 100-04, Chapter 26 (Completing and Processing Form CMS-1500 Data Set), Section 10.4 (Items 14-33 - Provider of Service or Supplier Information). This CMS manual can be found at the following CMS web site:

  3. #13
    Smile incident to
    Quote Originally Posted by kandigrl79 View Post
    I'm not exactly sure what you mean by "insurance" doctor. The doctor that you bill as the supervising physician is the doctor that the insurance company or payer will receive. Medicare says that in order to use a particular supervising physician he must have "direct supervision." This means that the physician must be present in the office suite and immediately available to provide assistance and direction while the is performing the service. If the doctor wasn't present on the premises then you can't use him to bill incident to. I hope this helps...
    I totally agree with everything Kandigrl79 wrote. I just want to add that since Dr B was the one present to comply to the incident to rule, Dr B must be used as the supervising physician when billing for the service...
    Marie L., CPC

  4. Default Physician's Office / Clinic vs. Facility / Outpatient
    Can someone clairify this further in that these responses are based on a physician's office or clinic. It is my understanding that the "incident to billing" regulations do not apply to facility billing in the outpatient setting.

  5. Default
    If you haven't already, refer to the following link of the Medicare Benefit Policy Manual and see if that is helpful for you in terms of the incident to for institutions. See section 60.

  6. Talking Incident to in Provider Based Clinic
    The incident to rule in location of "provider based clinic" just recently changed. As you can see below, the "treating physician" must be present in order to bill the incident to.

    20.5.1- Coverage of Outpatient Therapeutic Services Incident to a Physician's Service Furnished on or After August 1, 2000
    (Rev. 82; Issued: 02-08-08; Effective: 01-01-08; Implementation: 03-10-08

    Therapeutic services and supplies which hospitals provide on an outpatient basis are those services and supplies (including the use of hospital facilities) which are incident to the services of physicians in the treatment of patients. Such services include clinic services and emergency room services. Policies for hospital services incident to physicians' services rendered to outpatients differ in some respects from policies that pertain to “incident to” services furnished in office and physician-directed clinic settings. See the Medicare Policy Manual, Pub 100-02, Chapter 15,“Covered Medical and Other Heath Services”, section 60.
    To be covered as incident to physicians' services, the services and supplies must be furnished by the hospital or CAH or under arrangement made by the hospital or CAH (see section 20.1.1 of this chapter). The services and supplies must be furnished as an integral, although incidental, part of the physician's professional service in the course of treatment of an illness or injury.
    The services and supplies must be furnished in the hospital or at a department of the hospital which has provider-based status in relation to the hospital under 42 CFR §413.65 of the Code of Federal Regulations. The services and supplies must be furnished on a physician's order (or on the order of nonphysician practitioners working within their scope of work and the state and local policies) by hospital personnel and under a physician's supervision, as described below. This does not mean that each occasion of service by a nonphysician need also be the occasion of the actual rendition of a personal professional service by the physician responsible for care of the patient. However, during any course of treatment rendered by auxiliary personnel, the physician must personally see the patient periodically and sufficiently often to assess the course of treatment and the patient's progress and, where necessary, to change the treatment regimen. A hospital service or supply would not be considered incident to a physician's service if the attending physician merely wrote an order for the services or supplies and referred the patient to the hospital without being involved in the management of that course of treatment.
    The physician supervision requirement is generally assumed to be met where the services are performed on hospital premises. The hospital medical staff that supervises the services need not be in the same department as the ordering physician. However, if the services are furnished at a department of the hospital which has provider-based status in relation to the hospital under 42 CFR 413.65 of the Code of Federal Regulations, the services must be rendered under the direct supervision of a physician who is treating the patient. “Direct supervision” means the physician must be present and on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed

  7. #17
    Quote Originally Posted by djzetter View Post
    Another thing to be aware of is that you will want to make sure that all the physicians in the group, other than the supervisiing physician, are listed as assistant supervising physicians within your supervision/employment agreement with the PA and that this is filed with your state medical/osteopathic board. If you use a physician as a supervisor and they are not listed with your medical board as a supervising physician, then you are not compliant with state laws. This is the way it works in several states in which I have clients. You will need to check the state code and medical or ostepathic board regulations as these are usually more stringent than Medicare reimbursement regulations.

    Hope this helps.
    David is correct in what he is saying here, in our practice only the "partners" are supervising doctors and when our office schedule is made up, it list who is the "supervising doc" not just for billing incident to services but as a "go to doc" for that particular day.... it actually works out for us.

    Just my opinion
    Roxanne Thames CPC, CPC-I, CEMC

    "Remember the greatest gift is not found in the store but in the heart of true friends"

  8. #18
    Garden State Chapter, Cherry Hill, NJ
    Default Clinical Documentation Educator
    According to CMS guidelines, and most state guidelines, If the NP's scope of practice is with the "group entity" and you are billing "Incident To" which means the bill is being dropped under the billing (on-site) NPI number. Remember the 4 basic guidelines, est pt., est problem, physician in the site and out-patient only. You should be good to go.

  9. #19
    Our practice does the same. We have one doc listed as the supervising physician for the day that the NP's and our EPO clinic bill under UNLESS the attending is present in the office. It has helped us out tremendously!!

    Jennifer Sprague
    Syracuse, NY

  10. #20
    One more note, there are updates to the "incident to" rules that go into effect June 2, 2008. You can find them on the national website at:

    Jennifer Sprague
    Syracuse, NY

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