'Incident To' and Nonphysician Practitioner Services

Background
"Incident to" services are defined as those services that are furnished incident to physician professional services in the physician's office (whether the office is located in a separate building or is an office within an institution) or in a patient's home.

These services are submitted as Part B services to Palmetto GBA as if you personally provided them and are paid under the physician fee schedule.

Note: "Incident to" services are also relevant to services supervised by certain nonphysician practitioners such as physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives or clinical psychologists. These services are subject to the same requirements as physician-supervised services. Remember that incident services supervised by nonphysician practitioners are reimbursed at 85 percent of the physician fee schedule.

For clarity's sake, this article will refer to physician services as inclusive of nonphysician practitioners.

  • To qualify as "incident to," services must be part of your patient's normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment
  • You do not have to be physically present in the patient's treatment room while these services are provided, but you must provide direct supervision; that is, you must be present in the office suite to render assistance, if necessary
  • The patient record should document the essential requirements for "incident to" service
  • These services must be all of the following
    • An integral part of the patient's treatment course
    • Commonly rendered without charge (included in your physician's bills)
    • Of a type commonly furnished in a physician's office or clinic (not in an institutional setting)
    • An expense to you
    • Examples of qualifying "incident to" services include providing non-self-administrable drugs and other biologicals, and supplies usually furnished by the physician in the course of performing his/her services (e.g., gauze, ointments, bandages and oxygen)

The following paragraphs discuss the various care settings, which are important to note because the processes for billing vary somewhat depending on the care site.

Your Office

  • In your office, qualifying "incident to" services must be provided by a caregiver qualified to provide the service, whom you directly supervise, and who represents a direct financial expense to you (such as a W-2 or leased employee, or an independent contractor)
  • You do not have to be physically present in the treatment room while the service is being provided, but you must be present in the immediate office suite to render assistance if needed
  • If you are a solo practitioner, you must directly supervise the care
  • If you are in a group, any physician member of the group may be present in the office to supervise

Hospital or SNF

  • For inpatient or outpatient hospital services and services to residents in a Part A covered stay in a SNF the unbundling provision (1862)(a)(14) provides that payment for all services are made to the hospital or SNF by a Medicare intermediary (except for certain professional services personally performed by physicians and other allied health professionals)
  • "Incident to" services are not separately billable to the carrier or payable under the physician fee schedule

Offices in Institutions

  • In institutions including SNF, your office must be confined to a separately identifiable part of the facility and cannot be construed to extend throughout the entire facility
  • Your staff may provide service "incident to" your service in the office to outpatients, to patients who are not in a Medicare covered stay or in a Medicare certified part of a SNF
  • If your employee (or contractor) provides services outside of your office area, these services would not qualify as "incident to" unless you are physically present where the service is being provided
  • One exception is that certain chemotherapy "incident to" services are excluded from the bundled SNF payments and may be separately billable to the carrier

In Patients' Homes

  • In general, you must be present in the patient's home for the service to qualify as an "incident to" service
  • Exceptions to this direct supervision requirement apply to homebound patients in medically underserved areas where there are no available home health services only for certain limited services found in Pub 100-02. Chapter 15 Section 60.4 (B)
  • In this instance, you need not be physically present in the home when the service is performed, although general supervision of the service is required
  • You must order the services, maintain contact with the nurse or other employee, and retain professional responsibility for the service
  • All other "incident to" requirements must be met
  • A second exception applies when the service at home is an individual or intermittent service performed by personnel meeting pertinent state requirements (e.g., nurse, technician, or physician extender), and is an integral part of the physician's services to the patient

Signatures

Situation
Performed by
Signature Requirement
"Incident to"
 
Ancillary Staff
Must be signed by supervising (billing) provider
NPP (Nonphysician Practitioner)
May be signed by the NPP or the supervising (billing) physician

Billing Chart

Situation
Performed by
Billing
Established patient with no new problems 
NPP
If "incident to" requirements have been met the service may be billed under the supervising physician’s NPI
Established patient with new problem
NPP (only)
Must be billed under NPP’s NPI
Established patient with new problem
NPP and Physician
May be billed under physician if the “incident to” requirements have been met. The documentation must support a face-to-face occurred with the physician (during the encounter) and that he/she has initiated the course of treatment.  The physician must sign his/her entry.

References

  • MLN Matters Article SE0441 (PDF, 64 KB), "Incident to" Services
  • Benefit Policy Manual (PDF, 1.28 MB), Pub. 100-02, Chapter 15, Section 60
  • Palmetto GBA website article: Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices

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