Incident-to Billing: 101

 In Blog

There is no lack of information on the topic of “incident-to” billing. Unfortunately, much of it is so confusing that many practices are still left with questions. Here, we share the basic information you should know to stay compliant and avoid owing refunds.

The incident-to rule originated to allow Advanced Practice Providers [APPs] to be paid at the full physician rate by Medicare instead of the 85% allowed for a nonphysician. In the past, most insurers did not allow APPs to be credentialed as independent providers, so this was a way to avoid the reduction in payment.

An APP sees a patient in a non-institutional setting (all settings other than hospitals or skilled nursing facilities) and bills for the visit as incident-to because the physician is in the office and available. That sounds easy to follow, but the hard part involves the patient’s condition.

In order to bill the services as incident-to the patient must have an established plan of care and the APP service is just a part of that care.

The Medicare Benefit Policy Manual states:

“…[T]here must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the nonphysician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment.”

If the patient has a new condition, or a reaction to treatment, then the physician must get involved to create a new plan of care. That is the crux of the problem for many practices, and it’s not just a matter of clinical care decisions. There are many scenarios for which to prepare a workflow process:

  • What is said to the patient to explain the change in provider?
  • How is the physician notified?
  • How much time will lapse between the APP leaving and the physician arriving?
  • What is said to the patients already on the schedule for the physician?

Let’s consider the following example:

A general practitioner diagnoses a Medicare patient with hypertension and diabetes in January and creates a plan of care. The patient returns in March for follow-up with the nurse practitioner. At the follow-up visit, the patient complains of knee pain. Although the physician is in the office, the nurse practitioner evaluates and treats the patient for the new problem.

In this case, if the nurse practitioner had evaluated only the hypertension and diabetes, which were established diagnoses with a plan of care, the service would meet incident-to requirements. However, because the physician did not personally perform the initial service for the patient’s new complaint of knee pain, the service cannot be reported as incident-to. Instead, the NP (if properly credentialed) would report the service to Medicare under his or her own provider ID. Similarly, if a physician assistant sees Medicare patients in the office while the physician is at the hospital making rounds, incident-to billing is not appropriate because the requirement for direct supervision hasn’t been met (the physician must be physically present in the office suite).

Now that more insurers are accepting and credentialing APPs, there is a trend in practices to move away from incident-to billing under the physician and toward billing under the APP’s own NPI. These practices tend to consider the loss of the 15% payment less of a burden than trying to make sure the incident-to rules are followed correctly.

If you have additional incident-to questions, we can help. Please contact Laura Summy at LSummy@medicmgmt.com for support.

Laura Summy is Managing of coding of MMG Healthcare Solutions / Medic Management Group. MMG is a national provider of consulting services and back office administrative support to independent and system owned physician practice groups.  Additionally, MMG has been formally recognized as a multi-year Northeast Ohio Top Workplaces award winner.

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