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Incident to is MediCARE only

  1. #1
    Milwaukee WI
    Default Incident to is MediCARE only
    Clearnace Sale
    The official rules for "incident to" billing apply ONLY to Medicare (and perhaps your state's MedicAID if they follow Medicare to the letter).

    We do not bill "incident to." Our PAs and NPs are credentialed with Medicare and Medicaid and bill services they provide under their own names/NPI numbers.

    Our commercial carriers do not credential PAs and NPs. They ask that we submit services by these allied health professionals under the name/NPI of the supervising physician - which is what we do.

    Our coding/billing software allows us to enter the charges under the actual provider (i.e. PA Smith), while sending the claim out under the supervising physician (i.e. Dr Jones). This way we have a clear understanding of who actually provided the service.

    We have no problem getting paid - even when documentation is requested.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  2. #2
    Columbia, MO
    I disagee, Incident to is a Medicare policy section 2050 from the Medicare manual. However it is recognized that Medicare is the gold standard for all other carriers to look to. The AMA websit put out a ton of information on this about 2 years ago. They stated that when the commercial carriers do not credential your NPPs then you should request in writing a policy from that carrier that states that they set aside the Medicare policy of incident to and require that you submit the NPPs a physician claims. The problem being that many times the person you speak with on the phone does not understand the concept of incident to. They only know that they do not credential the NPPs. I have done extensive research in this area and when I question the adminitrative authorities of the major commercial carriers they all told me that their written policy on incident to is to follow the Medicare policy. When I tried more that once to get a statement in writing from those that would profess to just bill under the physician, they could not do so as that would violate the written company policy. So I would be very careful here. I am not saying you cannot for commercials bill under the physcian when the parameters of incident to are not met, I am saying to not totally believe what the person on the phone is saying and take the AMAs advice and get it in writing.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    I agree with Debra. We have run into this too. I forget the carrier but they told our billing staff "we don't cover PAs". So the billing staff said ok and billed it under the doctor. Turns out, they don't pay for services rendered by a PA at all, they are considered non-covered services and blind billing them was very incorrect.

    Another thing to watch for is many carriers are now starting to credential PAs that didn't in the past. We continued to bill PAs under the doctor incorrectly for almost 2 years to BC/BS because "thats how we always did it". No one checked to see if the credentialing process had changed. I thought it was odd that we were billing under the doctor and did research in 2009 and found out it had changed in 2007.

    We have also had several carriers tell us they follow CMS guidelines.

    Laura, CPC, CPMA, CEMC

  4. #4
    Evansville Indiana
    Default Incident to
    Same here. Most of our major carriers follow CMS guidelines regarding "incident to".

  5. #5
    Dover Seacoast New Hampshire
    I agree with F Tessa Bartels. Remember, we sign contracts with commercial payers to bill appropriately, which includes obtaining a credentialled status for our mid-levels if we're going to use them. There are often reimbursement differences for billing the services of a mid-level, so to bill them as incident-to, (as if the doc was providing the service) is not appropriate, and some commercial payers consider this fraudulent.

    Medicare is the gold standard for Medicare, but you must follow the billing guidelines for your commercial payers that you contract with. As much as we wish everything was standardized across the board; it is not. You have to follow your commercial payer guidelines as carefully as you follow CMS guidelines.

    Some payers do allow incident-to services, but you have to verify this with them in advance, not assume it's appropriate to bill that way.

    Sorry to disagree, but we've had experience with this issue.

  6. #6
    Evansville Indiana
    Default Incident to
    When this issue came up with us, we had an employee contact the major commercial carriers that we dealt with and most, if not all said that they follow CMS guidelines in regards to "incident to". The best way to handle this would be to assume nothing and to contact each carrier individually.

  7. #7
    Jacksonville, FL River City Chapter
    I agree with Tessa. Incident to is a Medicare concept that may but usually doesn't apply to commercial payers that allow credentialed physicians to use NPPs in the care of their patients.

    For commercial payers, I just call it what is is: "NPP billing using the number of the credentialed physician." To say that the NPP is billing "incident to" the physician implies that Medicare's incident to billing rules are in play, which unless specifically stated in your commercial contract, is not the case. The contract will usually have a reference acknowledging the fact that NPPs which are employed by and represent a cost to the credentialed physicians will be used to provide some services that will be billed by the credentialed physician. I don't know of many that go beyond that by saying that Medicare's incident to rules must be used. Or as some have mentioned, the contract may make no reference to NPPs, meaning you need to check to make sure that the payer is ok with your using them.

    Seth Canterbury, CPC, ACS-E/M
    Last edited by SCanterbury; 04-14-2010 at 02:49 PM.

  8. #8
    North Carolina
    I'm with Tessa, also...

    The creation of "incident to" was geared towards Medicare...

    AAFP has a really good article on this...

    When Medicare was enacted, Congress provided for payment to the physician who directly interacted with the patient but also recognized that physicians received help in their offices. The incident-to rules were established to cover services that are “an integral, although incidental, part of the physician’s personal professional services to the patient.” Because these services are so intertwined with those that physicians provide, a claim for nonphysician providers’ services that are incident to the physician’s service can be submitted as if the physician performed the service. The nonphysician providers are invisible on the claim form, and the claim is paid at 100 percent of the physician fee schedule. Keep in mind that the incident-to rules apply only to Medicare reimbursement. For information on how other payers reimburse for the services of nonphysician providers, see “Other payers” below.


    The incident-to rules described in the article pertain exclusively to Medicare reimbursement. Other payers may reimburse for nonphysician providers’ services differently, so it’s important to review the physician participation agreement for the managed care companies your practice contracts with as well as your state’s laws. This will help you determine whether physicians have complete leeway, as is often the case, to delegate services that are within their scope of practice to nonphysician providers. If such an approach is explicitly recognized in the provider agreement, the claims for nonphysician providers’ services should generally be submitted as if rendered incident-to, although the incident-to restrictions (e.g., required physician on-premises supervision) don’t pertain unless the payer specified that they apply. Many state laws allow a general delegation of authority with responsibility retained by the physician without requiring on-premises supervision. In situations where you are not a participating provider, the safest course is to follow the Medicare rules, because the rules can vary from payer to payer.
    Rebecca CPC, CPMA, CEMC

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