Incident-to billing offers two key benefits: First, the physician is reimbursed at 100% of the contracted rate with the payer, while NPPs typically are reimbursed at 80% or 85% of the contracted rate, so if an NPP can bill under the physician, the reimbursement is higher.
Full Answer
How are NPPs reimbursed by Medicare and Medicaid?
Likewise, state Medicaid programs and managed Medicare and managed Medicaid plans may set their own rules. For Medicare, a service that is provided by an NPP and reported to Medicare is reimbursed at 85 percent of the physician fee schedule when the NPP’s national provider identification (NPI) number is used.
What is the difference between NPI and incident-to services?
If the criteria are met, the service should be billed under the physician’s national provider number (NPI) and the practice receives 100 percent of the physician’s fee schedule for the service. Note that, incident-to services are only applicable to Medicare. Incident-to services are only applicable for charges billed to a Medicare contractor.
What are incident-to services under Medicare?
Services that are reported incident-to a physician’s services or as shared services are reported to Medicare under the physician’s NPI and are paid at 100 percent of the Medicare physician fee schedule. What are incident-to services? NPPs often render services that are incident-to procedures and care that the surgeon provides.
When does an NPP report a patient as a provider?
If an NPP sees a new patient or assesses an established patient for a new problem, the practice should report that service under the NPP’s provider number, not the physician’s. Additionally the physician must be in the suite of offices when the services are performed and must stay involved with the patient’s care.
Does Medicare Cover incident to billing?
Incident to billing applies only to Medicare. Incident to billing does not apply to services with their own benefit category. For Example: Diagnostic tests are subject to their own coverage requirements.
When billing for Medicare patients what is the advantage of incident to billing?
The “incident-to” billing rules provide an exception, allowing 100 percent reimbursement for non-physician services that meet the requirements detailed in the Medicare Benefit Policy Manual, Chapter 15, Section 60 (Services and Supplies Furnished Incident To a Physician's/NPP's Professional Service).
What is the modifier for incident to billing?
No, there is no modifier when you bill "incident to". You just bill using the physician's name and NPI number but make sure you are following the incident to guidelines.
What does Incident 2 billing mean?
Incident-to billing is a way of billing outpatient services (rendered in a physician's office located in a separate office or in an institution, or in a patient's home) provided by a non-physician practitioner (NPP) such as a nurse practitioner (NP), physician assistant (PA), or other non-physician provider.
What does incident to mean Medicare?
“Incident to” is a Medicare billing provision that allows a patient seen exclusively by a PA to be billed under the physician's name if certain strict criteria are met.
What is the advantage of incident to billing?
Under incident to billing, the mid-level services are actually billed under the physician's NPI number and not under their own number. It helps if you remember this concept as incident to billing has a large physician role that must be performed and documented in order to qualify for the 100% reimbursement.
What is an incident to claim?
What is a claim? An incident is any untoward or unexpected event resulting in injury, or having a serious potential for injury or damages. Claims are of two basic types: formal and informal. A formal claim results when you are served with a legal document or receive a letter from a claimant or attorney.
Does Medicare require the SA modifier?
Medicare does not accept modifier SA, and other payers may specify unique requirements.
What does Incident service mean?
“Incident to” services are defined as those services that are furnished incident to physician professional services in the physician's office (whether located in a separate office suite or within an institution) or in a patient's home.
What conditions must be met for you to bill incident to the physician receiving 100?
What conditions must be met for you to bill "incident to" the physician, receiving 100% reimbursement from Medicare? the physician must be on-site and engaged in client care. What is the NPI (national provider identifier)?
What is CPT incident E&M code?
The CPT® code 99211 is the only E&M code used for 'incident to' billing available to the physician clinic's ancillary staff members. Some of the other codes (in the range of 99212–99499) can, however, be billed 'incident to' by non-physician providers (NP, PA, CNS).
What does modifier sa mean?
SA = use when billing on behalf of a PA, ANP, or CRNFA for non-surgical services. (Modifier SA is used when the PA, ANP, or CRNFA is assisting with any other procedure that does not include surgery.)
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
In response to provider requests, Noridian Healthcare Solutions, LLC (Noridian) provides the following key points related to the “incident to” regulations in the outpatient hospital setting. Note: There is no "incident to" in the inpatient setting. Medicare may reimburse the costs of services provided either: 1.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
What is incident billing in Medicare?
Incident to billing allows non-physician providers (NPPs) to report services “as if” they were performed by a physician. The advantage is that, under Medicare rules, covered services provided by NPPs typically are reimbursed at 85 percent of the fee schedule amount; whereas, services properly reported incident to are reimbursed at the full fee schedule value.#N#To realize the benefits of incident to billing, you must follow the rules precisely. There are seven basic incident-to requirements, as detailed in the Medicare Benefit Policy Manual, Chapter 15, Section 60.#N#1. Incident to billing applies only to Medicare; and, the incident-to billing does not apply to services with their own benefit category. Diagnostic tests, for example, are subject to their own coverage requirements. “Depending on the particular tests,” the Benefit Policy Manual explains, “the supervision requirement for diagnostic tests or other services may be more or less stringent than supervision requirements for services and supplies furnished incident to physician’s or other practitioner’s services.” Similarly, pneumococcal, influenza, and hepatitis B vaccines do not need to meet incident to requirements. MLN Matters Number: SE0441 elaborates:
How many incident to billing requirements are there?
To realize the benefits of incident to billing, you must follow the rules precisely. There are seven basic incident-to requirements, as detailed in the Medicare Benefit Policy Manual, Chapter 15, Section 60. 1.
What is a benefit policy manual?
The Benefit Policy Manual explains, “Where supplies are clearly of a type a physician is not expected to have on hand in his/her office or where services are of a type not considered medically appropriate to provide in the office setting, they would not be covered under the incident to provision. ”.
What does a nurse practitioner do in the office?
Although the physician is in the office, the nurse practitioner evaluates and treats the patient for the new problem. In this case, if the nurse practitioner had evaluated only the hypertension and diabetes, for which there were an established diagnosis and plan of care, the service would meet incident to requirements.
What is E/M in Medicare?
If the patient has a new or worsened complaint, a physician must conduct an initial evaluation and management (E/M) service for that complaint, and must establish the diagnosis and plan of care. 4.
Can a NP report knee pain to Medicare?
Instead, the NP (if properly credentialed) would report the service to Medicare under his or her own provider ID.
Is auxiliary personnel covered by a physician?
If auxiliary personnel perform services outside the office setting , e.g., in a patient’s home or in an institution (other than hospital or SNF), their services are covered incident to a physician’s service only if there is direct supervision by the physician [e.g., the physician must be physically present to oversee the care].
Objective
To set forth the requirements for NPP billing for their services under the three models of reimbursement.
Policy
Professional services rendered by certain licensed non physician providers or NPPs may be billed directly to the Medicare program, provided that the services are within the NPP’s scope of practice, as defined by State law.
Incident to Billing by Non-Physician Providers (NPPs)
Under certain circumstances, services furnished by NPPs may be billed under a physician’s provider number as “incident to” the physician’s services. To be covered as “incident to” the services of a physician, the services must be:
Other Non-physician Providers
For practice information on other providers such as Certified Registered Nurse Anesthetists and Anesthesiologist Assistants, Nurse Specialists, please see this MLN Booklet (link is external and opens in a new window) detailing NPP coverage from CMS.
What percentage of Medicare reimbursement is provided by NPP?
For Medicare, a service that is provided by an NPP and reported to Medicare is reimbursed at 85 percent of the physician fee schedule when the NPP’s national provider identification (NPI) number is used. Services that are reported incident-to a physician’s services or as shared services are reported to Medicare under the physician’s NPI ...
What percentage of Medicare fee is paid to a physician?
Services that are reported incident-to a physician’s services or as shared services are reported to Medicare under the physician’s NPI and are paid at 100 percent of the Medicare physician fee schedule.
What is the code for surgical group?
A surgical group in this position typically reports place-of-service code 22, signifying the outpatient department.
Can SNF be covered by Medicare?
Such services can be covered only under the hospital or SNF benefit and payment for such services can be made to only the hospital or SNF by a Medicare intermediary. (See §80 concerning physician supervision of technicians performing diagnostic x-ray procedures in a physician’s office.)
Do commercial insurance companies require PAs to have physician supervision?
In many markets, commercial insurers enroll and credential APRNs but not PAs. There is no consistent national policy. States usually require that PAs have physician supervision, although that does not mean being physically in the same location when the PA provides services.
Is NPP an expense?
If the hospital employs the NPP, and the NPP is not an expense to the practice, the practice may not report and be paid for those services . Some hospitals employ NPPs to support their surgical groups. These NPPs are listed as an expense to the hospital on their Part A expense report.
Can a new patient be billed as incident to a physician?
Care provided to a new patient or an established patient with a new health care problem may never be billed as incident-to a physician service. If an NPP sees a new patient or assesses an established patient for a new problem, the practice should report that service under the NPP’s provider number, not the physician’s.
What is Medicare A15?
A15. If the resident’s stay is being paid for by a source other than Medicare or Medicaid AND the resident is residing in a Medicare/Medicaid dually-certified facility, follow the most stringent requirement. If the resident is residing in a Medica re only or a Medicaid only certified facility, then providers should follow the requirements for that specific certified facility.
What is CMS A2?
A2. CMS defined “initial comprehensive visit” in the November 13, 2003, S&C-04-08 and stated that NPPs may perform any medically necessary visits even if they occur prior to the initial comprehensive visits in both SNFs and NFs. Medically necessary visits that NPPs perform on or after November 13, 2003, may be billed to the carrier when collaboration and billing requirements are met in the SNF and NF setting. The Survey & Certification letter S&C-04-08, may be found at
Does CMS pay for face to face visits?
A3. No. CMS only pays for medically necessary face-to-face visits by the physician or NPP with the resident. Since the NPP is performing the medically necessary visit, the NPP would bill for the visit.
Can NPPs sign initial orders for SNF?
A8. NPPs may not sign initial orders for an SNF resident. However, they may write initial orders for a resident (only) when they review those orders with the attending physician in person or via telephone conversation and have the orders signed by the physician.