Medical Billing Blog

Maximize Reimbursement from Incident-To Billing

Posted by Ali Ziehm on Fri, Jun, 22, 2012 @ 13:06 PM

Maximize Reimbursement from Incident-To BillingBy Ralph Sitler III, JD -- Non-physician providers play an important role in medical practices these days, including nurse practitioners and a host of others.  Understanding how Medicare recognizes these midlevel providers for reimbursement purposes is important for any practice utilizing their services.  Compliance with Medicare guidelines for this type of billing is important if you want to be reimbursed correctly and stay on the right side of regulatory bodies.

Non-physician providers (NPP) (Nurse Practitioner or Physician’s Assistant) generally see patients under one of two sets of circumstances.  In the first of these scenarios, the NPP will see patients at a time when the physician is not present in the office.  Under this circumstance, the NPP must bill under his or her own provider number.  When an NPP sees a patient under these circumstances, it is permissible to bill Medicare for the services, but the practice will generally be reimbursed at a reduced rate.  Check your State’s CMS policy.

The second instance is when the NPP will see a patient and the doctor is in the office and not physically present in the exam room, perhaps seeing other patients.  This type of encounter is often referred to as “incident-to”.  When a visit is billed incident-to, Medicare will reimburse the practice at 100% of the allowed amount, as if the physician saw the patient personally.  To qualify for an NPP billing Medicare incident-to, some requirements must be met. 

  1. The first requirement is that the physician must be on-site.  The doctor need not actually see the patient personally at each individual visit, but he needs to be on the premises in the office suite in case he or she needs to be consulted by the NPP.
  2. The service must be an integral, although incidental, part of the physician’s professional service (hence the term “incident-to”).  This means that the physician must perform the initial service to the patient to establish a treatment plan.  Then the NPP is able to see the patient on subsequent visits and can bill Medicare incident-to for these visits.  The physician need not see the patient every time, but must, from time to time, see the patient often enough to show that they are taking an active role in managing the treatment plan for that patient.
  3. The services provided by the NPP must be a condition that has already been treated by the attending physician.   If a new complaint is documented, the attending physician must see the patient to determine a diagnosis and establish a treatment plan, and must also bill for these services.  After this process, the NPP can then oversee follow-up visits, which can be billed as incident-to.  This would exclude services not considered medically necessary.  It is also important to note that the services must be performed in the office setting and not in a hospital.  Furthermore, diagnostic testing is not eligible for incident-to coverage.

It is important to know and follow these rules so that these services can be billed properly.  If the incident-to rules are not followed properly, the potential exists that false incident-to claims may be filed, which would leave the practice vulnerable to regulatory scrutiny and significant penalties under the False Claims Act.

Stay tuned for another article that will cover the nuts and bolts of billing incident-to claims, in which we will go over specific examples of incident-to and non-incident-to encounters and show how to bill them properly.