Incident to Services for Medicare Patients

Incident to services is a Medicare provision which allows physician offices to bill for services provided by a Non-Physician Practitioner or nurse or medical assistant under the physician's provider number.  The service is then paid at 100% of the Medicare Fee Schedule. NPPs may bill services under their own provider numbers, but in that case, the services are reimbursed at 85% of the Medicare Fee Schedule.  The NPP must be operating within their state scope of practice.

Incident to rules are the source of confusion.  They represent high risk to the practice, because the 15% payment differential is significant.

Here's an overview:
•    This is a Medicare rule for services provided in place of service 11, office
•    If billing for a Non-Physician Practitioner (NPP) under the physician provider number, the physician must have seen the patient first for that problem, initiated the plan of care, and documented that the NPP will follow the patient
•    The physician must be in the office when the service is provided by the NPP
•    The care that is provided incident to must be for the same problem.  New problems must be billed under the NPP’s own provider number
•    The ordering physician (the one who initiated the treatment) must stay involved in the plan of care and this must be documented in the record.  This can be through chart review, discussion, alternating visits: how is left up to carrier discretion.
•    No new patients or new problems may be billed incident to.  That is, if your NPP sees consults or new patients, or sees an established patient for a new problem, bill that under their own provider/NPI number.
•    Do not bill the services of one physician as incident to another, just because you have not completed the credentialling
•    Documentation of incident to services should include:  the fact that this is done in follow up of Dr. Ordering’s plans, that this service is part of the plan, and that either Dr. Ordering was in the office or Dr. Supervising was in the office when the service was provided.  If a discussion took place, document that.
•    Diagnostic services, pneumoccal, influenza and hepatitis B do not need to meet these requirements. (Covered under different statutes/rules)

Download the two page resource attached to this article for more information.

See also: Shared services

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