“Incident to” is a Medicarebilling provision that allows PAs to bill Medicare under the physician’s NPI number, only if Medicare’s strict criteria for “incident to” billing are met: • Services are provided in a physician’s office or physician’s clinic; • Physician sees Medicare patient on initial visit, establishes a diagnosis and treatment plan.
Full Answer
What are the Medicare incident to billing requirements?
Incident to billing requirements are detailed in the Medicare Benefit Policy Manual, Chapter 15, Section 60. Incident to billing applies only to Medicare. Incident to billing does not apply to services with their own benefit category. Diagnostic tests are subject to their own coverage requirements.
Can a supervising physician bill Medicare for an incident?
† Furthermore, in the 2016 MPFS, CMS clarifies that in cases where the supervising physician is someone other than the referring, ordering, or treating practitioner, only the supervising physician may bill Medicare for the incident to service.
When does a physician have to employ an incident to service?
If the physician is a sole practitioner, the physician must employ the NPP. The incident to service must be of a type usually performed in the office setting and must be part of the normal course of treatment of a diagnosis or illness.
What is a incident to billing service?
Incident to billing services must take place in a "noninstitutional setting," which the Centers for Medicare and Medicaid Services (CMS) defines as: "all settings other than a hospital or skilled nursing facility."
Does Medicare allow incident to billing?
INCIDENT-TO SERVICES Must relate to a service initially performed by the physician. Must be performed under direct supervision – when the physician is in the office suite/building. Cannot be billed when more than 50 percent of the visit is for counseling or care coordination. May not include diagnostic testing.
What is an example of incident to billing?
For example, if the physicians in a group are at the office until noon but then all go to do rounds, the nonphysician providers' services may be billed incident-to a physician until noon and on their own numbers thereafter.
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.
Which services are not allowed to be billed incident?
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.
What is meant by incident to billing?
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 modifier do you use 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 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 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.
Can a physician Bill incident to another physician CMS?
The Centers for Medicare & Medicaid Services (CMS) has verified that a physician can bill for incident-to services rendered by another physician as long as all incident-to criteria is met.
When billing for Medicare patients what is the advantage of incident to billing?
The advantage is that, under Medicare rules, covered services provided by non-physician providers (NPPs) are typically are reimbursed at 85 percent of the fee schedule amount, whereas, services properly reported incident to are reimbursed at 100 percent of the full fee schedule value.
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).
Does optum allow incident to billing?
Optum does not recognize or allow incident-to billing unless required by State Medicaid or Federal regulations. Additionally, Optum does not allow incident to billing for commercial plans. Practitioners must bill under their own name and provider identification (NPI, TIN).
What is incident to a physician?
Incident to is defined as services or supplies that are furnished incident to a physician's professional services when 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 and services are performed in the physician's office or in the patient's home. To qualify for payment under the incident to rules, services must be part of the patient's normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the ongoing course of treatment.
What is Chapter 15 Section 60.4 B?
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.
What is a physician directed clinic?
In clinics, particularly those that are departmentalized, direct personal physician/nonphysician practitioner supervision may be the responsibility of several physicians/nonphysician practitioners, as opposed to an individual attending physician/nonphysician practitioner.
What does "immediately available" mean?
Immediately Available: CMS has clarified that "immediately available" means "without delay" so Noridian considers "immediately available" to mean the supervising physician is in the office suite or patient's home, readily available and without delay, to assist and take over the care as necessary.
What is a second exception for home care?
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.
Does Medicare cover homebound patients?
Medicare covers services rendered to homebound patients provided by non-physician practitioners under direct personal supervision, when the following criteria is met: The service is an integral part of the physician's/nonphysician practitioner's services to the patient;
Can a nonphysician supervise a physician?
The physician/nonphysician practitioner cannot hire and supervise a professional whose scope of practice is outside the provider's own scope of practice as authorized under State law or whose professional qualifications exceed those of the "supervising" provider. For example, a CNM may not hire a psychologist and bill for ...
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 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].
Do you have to be present in the same room with your aide?
Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.
What is incident billing?
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 non-physician providers (NPPs) are typically are reimbursed at 85 percent of the fee schedule amount, whereas, services properly reported incident to are reimbursed at 100 percent of the full fee schedule value.
Who must be employed by the group entity billing for the incident to service?
Both the credentialed physician and the qualified NPP providing the incident to service must be employed by the group entity billing for the service. If the physician is a sole practitioner, the physician must employ the NPP. The incident to service must be of a type usually performed in the office setting and must be part of the normal course ...
Does incident to billing apply to Medicare?
Incident to billing requirements are detailed in the Medicare Benefit Policy Manual, Chapter 15, Section 60. Incident to billing applies only to Medicare. Incident to billing does not apply to services with their own benefit category. Diagnostic tests are subject to their own coverage requirements.
Is auxiliary personnel covered by a physician?
If auxiliary personnel perform services outside the office setting , e.g., in a patient’s home or 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].
Can incident to services be rendered on first visit?
Incident to services cannot be rendered on the patient’s first visit, or if a change to the plan of care occurs. A Medicare-credentialed physician must initiate the patient’s care. 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 ...
Is a diagnostic test subject to its own coverage requirements?
For Example: Diagnostic tests are subject to their own coverage requirements. “Depending on the particular tests, 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.
Is incident to billing a Medicare or Medicaid?
Incident to billing services must take place in a "noninstitutional setting," which the Centers for Medicare and Medicaid Services (CMS) ...
What is incident to Medicare?
“Incident to” is a Medicare billing provision that allows PAs to bill Medicare under the physician’s NPI number, only if Medicare’s strict criteria for “incident to” billing are met:
Does PA have to pay 15 percent?
Yes. Some practices choose to forego the additional 15 percent reimbursement to simplify billing. In their view, the increased volume of patients treated by the PA leads to enhanced revenue, making up the 15 percent differential, and reducing patient wait times. Additionally, the administrative burden required to ensure compliance with the strict criteria, as well as the risk of error and penalties if discovered in audit, far outweighs the 15% differential.
What is incident to services?
Incident to services are services rendered to a patient by a provider other than the physician treating the patient more broadly, that are an integral, although incidental, part of the patient’s normal course of diagnosis or treatment of an injury or illness. These services are billed as Medicare Part B services, ...
What is a physician's bill?
An integral, although incidental, part of the physician’s professional service. Commonly rendered without charge or included in the physician’s bill. Of a type that are commonly furnished in physicians’ offices or clinics. Furnished by the physician or by auxiliary personnel under the physician’s direct supervision.
Can a surgical group be reported to Medicare?
If a surgical group joins a hospital as part of an off-campus outpatient hospital, even if the group is in the same location it was in before joining the hospital, incident to services can no longer be reported to Medicare. In this situation, the place of service is no longer the office, but a hospital outpatient department.
What is incident to services?
Note: “Incident to” services are also relevant to services supervised by certain non-physician 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 non-physician 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 non-physician practitioners.
Can an incident to billing be confusing?
Incident-to billing can be confusing. Unfortunately, many NPs find their employers want to bill under incident-to, yet there is often a mis-understanding of this issue, as we’ve t alked about before. The problem is it can potentially result in fraud charges if the rules are not followed.