Incident To Self-Service Tool   

The purpose of the “Incident To’ self-service tool is to assist providers with understanding the CMS Part B ‘incident-to’ requirements and to apply the rules to their individual given patient/provider circumstances and to understand documentation requirements

Use of this tool is not a guarantee of coverage nor meant to imply coverage, but rather is intended to be a tool to assist providers in understanding coverage criteria and applying that criteria based on self-reported circumstances of a given patient encounter. Medicare will continue to require that all documentation and coverage requirements are met.

Decision Tree

1.) Is this a new patient seen by someone other than the billing provider?

  • Yes 2
  • No 3
'Incident To' rules do not apply.

‘Incident To’ a physician’s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.

Coverage of services and supplies incident to the professional services of a physician in private practice is limited to situations in which there is direct physician supervision of auxiliary personnel.

2.) Does the person performing the service meet the definition of ‘auxiliary personnel?’

Auxiliary personnel means any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician. Likewise, the supervising physician may be an employee, leased employee or independent contractor of the legal entity billing and receiving payment for the services or supplies.

However, the physician personally furnishing the services or supplies or supervising the auxiliary personnel furnishing the services or supplies must have a relationship with the legal entity billing and receiving payment for the services or supplies that satisfies the requirements for valid reassignment. As with the physician’s personal professional services, the patient’s financial liability for the incident to services or supplies is to the physician or other legal entity billing and receiving payment for the services or supplies. Therefore, the incident to services or supplies must represent an expense incurred by the physician or legal entity billing for the services or supplies.

Thus, where a physician supervises auxiliary personnel to assist him/her in rendering services to patients and includes the charges for their services in his/her own bills, the services of such personnel are considered incident to the physician’s service if there is a physician’s service rendered to which the services of such personnel are an incidental part and there is direct supervision by the physician.
  • Yes10
  • No6

-

  • Less than 5 8
  • 5 or more 5

-

  • $2 million or more 9
  • Less than $2 million7

‘Incident To’ rules do not apply. Service can only be billed under the performing provider’s NPI if that provider is eligible to enroll as a Medicare provider.
The person does not qualify for a membership
The person qualifies for a discounted membership
The person qualifies for a regular membership

3) Is the service being provided in place of service 19 or 22 (outpatient hospital), or 23 (emergency department)?

  • Yes12
  • No13
The person qualifies for a regular membership
'Incident To’ rules do not apply in these locations.

4) Is the patient being seen in a NF or SNF?

  • Yes14
  • No16

4 a) Is the billing provider in the NF/SNF at the time the service was rendered providing supervision of the performance of the service in an office in the NF/SNF that is confined to a separately identifiable part of the facility?

  • Yes16
  • No15
The office cannot be construed to extend throughout the entire facility.

‘Incident To’ rules do not apply.

5) Is the auxiliary personnel perform services outside the office setting, e.g., in a patient’s home or in an institution (other than hospital or SNF)?

  • Yes17
  • No18

5 a) Is the billing provider providing direct supervision at the time the service was rendered?

  • Yes18
  • No25

6) Is the patient being seen for a new problem?

  • Yes19
  • No20

‘Incident To’ does not apply. ‘Incident To’ rules require that the patient has been seen by a provider in the group and a course of treatment initiated for which the service being performed is incidental.

7) Is the billing provider (provider whose individual NPI is being used to bill the service) in the office or suite of offices at the time the service was rendered?

  • Yes22
  • No21

‘Incident To’ does not apply. ‘Incident To’ rules require the billing provider be physical present in the office or suite of offices to provider supervision when the service was provided.

8) Does the medical record indicate that the patient was initially seen by the billing provider or a provider in the group?

  • Yes24
  • No23
'Incident to' would not apply. There must have been a direct, personal, professional service furnished by the physician or physician in the group to initiate the course of treatment. A service cannot be submitted 'incident to' even when the NPP only orders diagnostic or laboratory tests, unless the physician provides a face-to-face encounter and establishes the course of treatment (need for X-ray, apply ice, etc.).

9) Does documentation support that there has been a direct, personal, professional service furnished by the physician or physician in the group to initiate the course of treatment?

  • Yes26
  • No25

‘Incident To’ does not apply.

10) Does documentation for the service billed include a legible signature of the billing provider (the provider providing the direct supervision and whose individual NPI number is being used to bill for the incident to service)?

  • Yes28
  • No27
'Incident To' does not apply and documentation does not support a billable service by the billing provider as incident to.
If all ‘Incident To’ and documentation requirements have been met, the service may be billed as ‘Incident To’. Review CMS IOM Publication 100-02, Chapter 15, Sections 60.1 and 60.2 for official regulation. Regulation and Guidance Manual.