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Thread: "Incident To" in an Outpatient setting

  1. #1

    Exclamation "Incident To" in an Outpatient setting

    AAPC: Back to School
    Hi All...

    I have read where "Incident To" billing can not be used in a hospital for either IP or OP services. What if, per contractual agreement, we are running a clinic out of a hospital owned facility....not located in the main facility. We are not "renting" the space, per se'...but are under contractual obligation to provide a certain number of Physician and Physician Extender hours.....

    The article I am reading states that the only exception to OP services would be if the Physician would be renting space from the hospital...we are not actually renting - no monetary compensation is exchanged for our services. We bill for the professional component and have been using POS 22...

    Can we use "Incident To" in the form of a CNP with a supervising Physician in the suite? I hope so as we just hired a new CNP (not yet credentialed) to help in this facility.....

    Thanks for any and all comments...
    Last edited by g.fairchild; 09-21-2010 at 01:37 PM.

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    Incident to does not apply to facility billing, it does apply to physician billing in any place of service.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Join Date
    Apr 2007


    I was dealing with this issue recently, and I got clarification from my Medicare carrier that the place of service used for billing is the defining factor. If your clinic bills as POS 11, then incident to would be applicable. I'd be interested to see if anyone else has input.
    Jenny Berkshire, CPC, CEMC, CGIC

  4. #4


    Quote Originally Posted by j.berkshire View Post
    I was dealing with this issue recently, and I got clarification from my Medicare carrier that the place of service used for billing is the defining factor. If your clinic bills as POS 11, then incident to would be applicable. I'd be interested to see if anyone else has input.
    This is rather confusing...as I always understood POS 11 to be the Physician's private office, and in running this clinic, we have always used POS 22 (it is not an ASC).

    Should we have been using POS 11 instead....

  5. #5


    I pulled two documents from the CMS website: "POS Codes for Professional Claims" and the IOM Manuel (Medicare's Billing Bible)...here are sections I found that pertain:

    POS Codes for Professional Claims

    11 - Office: Location, other than a hospital, SNF, military treatment facility, community health center, State or local public health clinic, or ICF, where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis. From this descriptive, our OP clinic would not be coded POS 11 because we are considered part of the hospital, and the NPI associated with that location is an outpatient facility.

    IOM Manuel: 100-04, Chapter 12, Section 30.6.1, B. Selection of level of E&M Service

    Split/Shared E/M Service - Hospital IP/OP/Emergency Dept Setting

    When a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's UPIN/PIN number. However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient‟s medical record) then the service may only be billed under the NPP's UPIN/PIN. Payment will be made at the appropriate physician fee schedule rate based on the UPIN/PIN entered on the claim

    So does this not justify using a POS 22 AND billing the professional component as a "shared/split" service...if the "incident to" requirements are met?? This is how I am taking this...

    Any other thoughts???

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