Medicare Incident-to Billing Rules, Pitfalls

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In today’s busy rheumatology practices, the services of nurse practitioners, physician assistants, occupational therapists and clinical nurse specialists are a great asset for patient flow, as well as increased revenue. As the growth of nonphysician providers (NPPs) in rheumatology practices has evolved, it has become increasingly important to understand the incident-to rules and avoid the pitfalls of Medicare’s coding and billing guidelines.

Incident-to billing is a specific method of billing developed by the Centers for Medicare and Medicaid Services (CMS) for NPPs working in physician practices. Under incident-to billing, outpatient services by an NPP may be billed and reimbursed under the physician’s name and provider ID as if the physician personally performed the service. The Medicare Benefit Policy Manual defines incident-to as, “services or supplies furnished as an integral, although incidental, part of a physician’s personal professional service” and reimbursable at 100% of the Medicare fee schedule under the physician.¹

Although office visits are perhaps the most commonly billed service under the incident-to guidelines, incident-to services are not limited to a specific set of procedure codes or services. As long as the NPP is performing services within the scope of their license, the procedure code description requirements are met, and the incident-to requirements are fully met, the services may be billed to CMS as an incident-to claim.

Key Criteria

For claims billed to Medicare as incident-to services, an NPP must meet specific criteria, including:

• The NPP must be licensed or certified to provide professional healthcare services in the state where he/she practices;
• The NPP must be a full-time, part-time or leased employee of the organization or employee of the legal entity that employs the supervising qualified Medicare provider;
• The service must be an integral, although incidental, part of the physician’s service;
• The service must be commonly rendered without charge or included in the physician’s bill;
• The service must be commonly furnished in a physician’s office or clinic;
• The service must be in the scope of practice of the NPP; and
• The NPP must provide the services under the direct supervision of the physician (unless otherwise specified by state requirements).

If the above rules are not met, the NPP can still perform the service, but it should not be billed as incident-to. The claim would have to be billed under the NPP’s NPI number, and reimbursed at 85% of the Medicare fee schedule.

The foundation of proper incident-to billing is that any incident-to service must be an integral part of the physician’s services. The guidelines indicate that the physician must initially assess and create a treatment plan for the patient whom the NPP is treating incident to the physician’s services. This requirement does not mean the physician has to see the patient at subsequent visits, but he or she must remain actively involved in the course of treatment.² Rather, the NPP will oversee and manage an ongoing course of treatment initiated by the physician. However, if an established patient reports a new chief complaint or problem during an office visit, the physician would then have to see the patient again for the new issue in order to be able to bill for the NPP’s services as incident-to.