Submitting Incident to Billing Claims

January 15, 2021

To many physicians and medical practice staff members incident to billing can be a somewhat confusing concept. When billed “incident to” for services provided by a non-physician practitioner (NPP), like a nurse practitioners, physician assistants or clinical nurse specialists, the Medicare claim is submitted under the physician’s National Provider Identifier (NPI) number, and not the NNP’s. This results in reimbursement at 100 percent of the fee schedule instead of the 85 percent that is paid when billed under the NPP’s NPI.

Submitting Incident to Billing Claims

There are criteria, of course. According the Centers for Medicare and Medicaid Services (CMS), to be billed as “incident to” a service must be part of the patient’s normal treatment course, a physician must have performed the initial service and the physician must remain actively involved in the patient’s treatment. Furthermore, the physician must provide “direct supervision,” which really means available in the office suite if needed. What follows are the specifics of the qualifying criteria, as detailed in the Medicare Benefit Policy Manual, Chapter 15, Section 60.

Incident to services must be performed in a non-institutional setting, which CMS defines as any place other than a hospital or skilled nursing facility.

A physician with Medicare credentials must initiate the patient’s healthcare, and incident to services cannot be provided on the patient’s first visit. If the patient develops a new symptom, or if symptoms worsen, the physician must conduct another evaluation and establish a diagnosis and treatment plan before the NPP can provide additional services that can be billed incident to.

To qualify as incident to an NPP’s care care must occur under the direct supervision of a qualified physician. In this context, direct supervision means that the physician is present in the office suite and available to provide assistance immediately if needed. The assisting physician does not have to be the one who initially saw the patient and is overseeing their treatment.

There must be a physician who participates actively in and manages the patient’s treatment plan. In most cases the active participation requirements are spelled out by state licensure rules concerning NPP supervision. The physician and the NPP providing the incident to service must both be employed by the organization that is submitting the bill.

If the NPP’s service meets all of these qualifications, it can be billed as incident to under the physician’s NPI, however, the submitted claim should include details about who performed the service and what physician was on hand to assist.

Keep in mind that incident to billing only applies to Medicare and should not be used if the service performed has its own benefit category. ProMD Practice Management offers consultation services and staff training that could help insure proper billing procedures at your medical practice. Contact us today to learn more.

ProMD Practice Management is happy to help with your billing assessment needs so you can maximize profits and increase patient satisfaction. To learn more about how ProMD can make your practice run like a well-oiled machine, call 888-622-7498 or fill out our online form to request a billing assessment.

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