Should You Bill Incident to Services for a Medicare Patient Under The Number of the “Supervising Physician” or the “Ordering Physician”?
This issue was first clarified in the preamble of the 11/1/01 Federal Register (available here on p. 23 of the file, p. 55267 of the document):
Comment: Several commenters requested that we clarify and distinguish between the physician (or other practitioner) ordering the incident to service and the physician (or other practitioner) supervising the auxiliary personnel who perform the incident to service. They stated that confusion exists as to whose Medicare Part B billing number should be used on the claim form.
Response: Inherent in the definition of an incident to service is the requirement that the incident to service be furnished incident to a professional service of a physician (or other practitioner). When a claim is submitted to Medicare under the billing number of a physician (or other practitioner) for an incident to service, the physician is stating that he or she either performed the service or directly supervised the auxiliary personnel performing the service. Accordingly, the Medicare billing number of the ordering physician (or other practitioner) should not be used if that person did not directly supervise the auxiliary personnel. We added language to the supervision requirement set forth in § 410.26(b)(5) to reflect this clarification.
The language added to the federal regulation mentioned above (found on p. 2 here) was this:
(5) Services and supplies must be furnished under the direct supervision of the physician (or other practitioner). The physician (or other practitioner) directly supervising the auxiliary personnel need not be the same physician (or other practitioner) upon whose professional service the incident to service is based.
This clarification was manualized via Transmittal 148 (Change Request 3138) on 4/23/04. The field designations mentioned in that transmittal have since changed, so instead of quoting from that, here are relevant excerpts from the current [as of 10/16/09] manual (Claims Processing Manual, Chapter 26, Section 10.4 here):
Ordering physician - is a physician or, when appropriate, a non-physician practitioner who orders non-physician services for the patient.
When a service is incident to the service of a physician or non-physician practitioner, the name of the physician or non-physician practitioner who performs the initial service and orders the non-physician service must appear in item 17
Item 17b Form CMS-1500 – Enter the NPI of the referring/ordering physician listed in item 17. All physicians who order services or refer Medicare beneficiaries must report this data.
Item 24J - Enter the rendering provider’s PIN in the shaded portion. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the PIN of the supervisor in the shaded portion.
Enter the rendering provider’s NPI number in the lower unshaded portion. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the NPI of the supervisor in the lower unshaded portion.
Item 31 - Enter the signature of provider of service or supplier, or his/her representative, and either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alpha-numeric date (e.g., January 1, 1998) the form was signed.
In the case of a service that is provided incident to the service of a physician or non-physician practitioner, when the ordering physician or non-physician practitioner is directly supervising the service as in 42 CFR 410.32, the signature of the ordering physician or non-physician practitioner shall be entered in item 31. When the ordering physician or non-physician practitioner is not supervising the service, then enter the signature of the physician or non-physician practitioner providing the direct supervision in item 31.
NOTE: This is a required field, however the claim can be processed if the following is true. If a physician, supplier, or authorized person's signature is missing, but the signature is on file; or if any authorization is attached to the claim or if the signature field has "Signature on File" and/or a computer generated signature. [All emphasis (in red) in the manual quote above was added.]
Based on the information above, the “rendering provider” (the person you bill under) for the later incident to service is the “supervising physician”—the one meeting the “direct supervision” requirement for the incident to service by being “in the office suite”, not the original “ordering physician”—the one initiating care but not “in the office” for the subsequent encounter. However, the ordering physician’s information must still be noted on the claim when it was a different provider from the one supervising the later incident to service.
Seth Canterbury, CPC, ACS-EM
University of Florida Jacksonville Physicians, Inc.
Clinical Data Quality-Education Department
653 West Eight Street
Tower I, Suite 606
Jacksonville, FL 32209