Incident to Services for Medicare Patients

April 24th, 2013 - Codapedia Editor
Categories:   Medicare   Primary Care|Family Care  
0 Votes - Sign in to vote or comment.

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



Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.

Latest articles:  (any category)

Things to Consider Before Upgrading Medical Billing Software
August 11th, 2022 - Find-A-Code
Your practice has utilized the same medical billing software for years. The medical billing staff says it is time for a change. You don't necessarily disagree, but you also don't know where to begin your search for new software. There are so many vendors offering so many products that making sense of it all can be challenging.
Calendar Year 2023 Medicare Advantage and Part C & D Payment Policies
August 9th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Each year CMS publishes an Advance Notice of the upcoming years Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies and asks for comments related to it. Each of the comments are carefully reviewed and responded to and often are impactful to changes seen between the Advance Notice and final publication referred to as the Rate Announcement. With health equity as a primary focus for 2023, CMS announced some policy changes that may impact your organization.
How CMS Determines Which Telehealth Services are Risk Adjustable
August 9th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Medicare Advantage Organizations (MAOs) have gone back and forth on whether or not to use data collected from telehealth, virtual Care, and telephone (audio-only) encounters with Medicare beneficiaries for risk adjustment reporting, but the following published documents from CMS cleared that up once and for all by providing an answer to a question specifically related to this question.
OIG Investigates SCAN Health for Risk Adjustment Overpayments With Surprising Results
July 26th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
We’ve seen a number of OIG risk adjustment data validation (RADV) audits recently where the independent review contractor was simply looking for any codes the payer reported that were not supported by the documentation, in an effort to declare an overpayment was made and monies are due to be repaid. However, it was refreshing to read this RADV audit and discover that the independent review contractor actually identified HCCs the payer failed to report that, while still resulting in an overpayment, was able to reduce the overpayment by giving credit for these additional HCCs. What lessons are you learning from reading these RADV audit reports?
Addressing Trauma and Mass Violence
July 21st, 2022 - Amanda Ballif
After events of mass violence, it’s easy to feel helpless, like there is little we can do. In fact, we can help individuals, families, and communities build resilience and connect with others to cope together. The SAMHSA-funded National Child Traumatic Stress Network has developed a range of resources to help children, families, educators, and communities including the following which you can access via links in this article.
The 'Big 2' HIPAA Rules Medical Billing Companies Must Follow
July 20th, 2022 - Find-A-Code Staff
HIPAA covers nearly every aspect of how medical and personal information is collected, utilized, shared, and stored within the healthcare industry. Title II of the rules is applied directly to medical billing companies and independent coders. The 'Big 2' rules that medical billing companies must adhere to revolve around privacy and security.
The Beginning of the End of COVID-19-Related Emergency Blanket Waivers
July 19th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
It appears that the end of the 1135 waivers related to the COVID-19 public health emergency (PHE) has begun. According to CMS, the residents of skilled nursing facilities, long-term care facilities, and inpatient hospice centers have struggled due to the effects of some of the 1135 waivers. CMS is focusing primarily on removing the 1135 blanket waivers that pertain to certain aspects of care, training, and maintenance of these facilities to ensure the weakest of our citizens are guaranteed adequate care.

Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2022 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association