Billing Incident-to Services

I can’t tell you how many times I have heard practices say, “We don’t bother with incident-to billing. We just bill all of our Medicare services under the physician’s provider number.” Not true. Billing under the physician’s provider number for services provided by someone other than the physician is clearly incident-to billing.

Let’s start with Medicare’s own definition, from the MLN Matters bulletin:

“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. ... These services are paid at 100 percent of the physician fee schedule, while services reported by Non-Physician Practitioners are paid at 85 percent.”

Just like real estate, incident-to services are all about location. Specifically, the services may be provided only in a physician’s office or in the patient’s home. If a physician rents space in a facility, and the practice is independent (not a department of the hospital or a provider-based clinic, for example) then the physician may bill incident-to services in that office. However, if the physician service is provided in an inpatient or outpatient hospital location or in a nursing facility, the group may not bill incident-to services. That is, you may not report services provided by a nonphysician practitioner or any other staff member under the physician’s provider number.

While we’re talking about location, remember that the physician must be in the office when incident-to services are provided. Not at the hospital, on vacation, or en route. If the physician who ordered the services is not available, the physician’s partner may supervise the service. In this instance, report the service under the supervising physician’s number.

• Don’t forget the additional requirements for incident-to billing:

• The service must be an integral part of the patient’s treatment course;

• It must have been initiated by a physician at a previous encounter;

• The physician must stay involved in the treatment plan, and be in the office when the service is provided (or a supervising partner); and

• The service must be an expense to the physician’s practice.

And, here are some common pitfalls to watch out for:

Updates to your software. When you update your billing software, make sure that the fields that draw provider numbers are correct.

Hiring new nonphysician practitioners. You have two choices here: Submit all claims under the NPP’s own provider number and accept 85 percent reimbursement; or educate the NPP about incident-to rules and let the NPP decide if the established patient visit meets the requirements of incident-to billing. If the NPP is treating an existing problem, under an existing treatment plan, and the physician is in the office, bill under the physician. New patients and new problems must be billed under the NPP’s provider number.

Seen and agreed. Here, the physician steps into the room and says “Hello, I agree with the NPP’s plan.” Some specialty practices schedule the NPP and the physician to see a patient on the same day. If the visit is documented by the NPP it should be billed to Medicare under the NPP’s provider number, not the physician’s number. This circumstance does not meet the requirements of incident-to billing.

It is important to take the time to review these rules with your billing staff, nonphysician practitioners, and physicians, so that everyone understands exactly what incident-to billing requires. You’ll rest easier at night knowing your practice is compliant and audit ready.

Betsy Nicoletti is the founder of Codapedia.com. She is also the author of “A Field Guide to Physician Coding.” She believes all physicians can improve their compliance and increase their revenue through better coding. She may be reached at betsy.nicoletti@gmail.com or 802 885 5641.