Everything You Want to Know About “Incident to Billing”

MGMA has reported that many physician-owned multi-specialty practices and groups often use non-physician providers (NPPs). According to the report, the reason is that the NPPs with the practices often generate higher income than physicians and are financially more viable.

NPPs, however, need to function directly under the supervision of a physician to provide billable medical services. Therefore, registered nurse aestheticians, surgeons, or physicians’ assistants can be included in the facility under the NPPs.

Further under the Medicare fee schedule, the NPPs’ medical practices can receive full payment and reimburse the amount for the services successfully by reporting the NPSS services under ‘incident-to’ for physician care.

But CMS has implemented strict and complex guidelines for incident-to billing. That’s why physicians must understand the rules of the medical billing procedures correctly to receive full payment from the insurers for the services rendered by NPPs. The physicians/ billing staff also need to be aware of any misapplying of the conditions in the incident-to billing. Misapplication of the condition in the medical billing and coding further increases the chances of coming under the CMS’s radar for fraudulent claims.

Hence, most centres that offer NPPs prefer to work with medical billing services to overcome the challenges of incident-to billing.

What Should Physicians Know About Incident-To Billing?

Here are some key points that a physician needs to know about incident-to billing for an office visit.

  • There is quite a bit of ambiguity in the term ‘supervising physician.’ The CMS states that a medical billing or supervising physician does not necessarily have to be the original physician or ordering physician on the patient’s case.
  • It is possible that the rules for incident-to billing a credentialed physician must make the diagnosis of the patient and set up a care plan. After this, the NPP can conduct a follow-up visit that can be billed to the incident-to, which complies with a detailed and defined plan.
  • Furthermore, a supervising physician can have the same rules, but it is not mandatory. They have to set up a plan of care. But it is vital that the incident-to services must be reported under the physician and their number who supervises the actual NPPs services.
  • In the care of a patient, the provider under whose name the service is performed must be involved in the medical billing.
  • For any new problems, the initial visit seen by a physician must have established Medicare patients.
  • The services rendered must be in the office, and both the NPP and the physician must be employees of the same facility.
  • The services that can be provided for incident-to-billings are usually performed in a clinic or physician’s office. The likes can include low acute services, setting casts, readjusting simple fractures, minor surgery, X-ray readings, etc.
  • For an incident-to billing the under, Medicare must have the physician (supervisor) onsite. It is known that many states allow the physician’s assistant to practice under general supervision. However, it does not satisfy the Medicare rules for incident-to billing.
  • The nurse practitioner cannot bill into incident-to when performing a service. Medicare specifies that time refers to the time spent with the physician. Hence, coordination care or counselling that is more than 50% of the physician’s time is the key criterion in selecting the E&M level of service.
  • For services offered as part of partial hospitalization and hospital, outpatients can be billed to incident-to services under the CMS rules.

How Are Incident-To Services Coded?

Additional modifiers are not required when coding for incident-to-services. Instead, the standard CPT, HCPCS, and ICD codes can be used.

When the coding is correct, Medicare reimburses for the services provided under incident-to by the NPPs for the total fee schedule amount. However, the submitting rules for incident-to billing differ for commercial payers from Medicare.

How To Be Incident-To Billing Complaint?

The failure to have proper incident-to-billing compliance can mean a massive amount of settlements being paid for the failure to comply with the rules. For instance, in February of 2020, a family physician in Ohio had to pay $285,000 to settle the allegation of failure to supervise nurse practitioner services billed at a higher physician rate.

There have been so many fraudulent, wasteful and abusive incidents-to billing practices that raise the cost of healthcare in the US. Hence, the OIG and DOJ spend quite a lot of their resources and time investigating false claims based on their audit or a complaint by a whistle-blower.

But it is easy to stay on the path and get 100% reimbursement for the incident-to services provided by understanding how to do the incident-to billing appropriately and learning the compliance rules and regulations and the risks—also the knowledge of how to avoid the issue of non-compliance.

Undoubtedly, training your staff and staying on top of the changing regulations can be a challenge. But simultaneously, when you partner with an expert medical billing and coding company that specializes in incident-to billing such as 24/7 Medical Billing Services, you will soon experience the benefit of having NPPs service. Also, you can enjoy the benefit of having an efficient revenue management cycle in place for better ROI while increasing the scalability of your facility by outsourcing medical billing and coding.

Read more: CMS Issues New Policies To Provide Greater Transparency For Medicare Advantage And Part D Plans  

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