Incident to Billing: Unravelling the Complexity in Medical Practices

Using non-physician practitioners (nurse practitioners, physician assistants, clinical nurse specialists, and so on) to boost productivity in a medical practice is an effective strategy to do so. However, covered services delivered by non-physician practitioners (NPPs) are reimbursed at a lower rate (85% of the fee schedule amount) under Medicare rules. The “incident-to” billing for services rules provide an exception, enabling 100 percent reimbursement for non-physician treatments that meet the guidelines outlined in Chapter 15, Section 60 of the Medicare Benefit Policy Manual.

The term “incident to” a physician’s professional services denotes that the services or supplies are provided as an integral, although incidental, element of the physician’s professional assistance during the diagnosis or treatment of an accident or sickness. However, the ability to use “incident to” charging is subject to several constraints and limits. Let’s have a look at such complexities:

Complexities with Solutions

Incident-to-billing is one of the last remaining ways physicians can expand their services and improve their earnings without working harder. However, the regulations regulating this practice under the federal Medicare program and the various state Medicaid programs can create hazards to naïve physicians and their staffs who fail to comprehend and apply them properly. These errors may result in government intervention, audits, overpayment demands, and false claim allegations. That’s why there is a need to be aware of the various complexities involved with solutions to deal with it.

  • Part of the Physician’s Services

The incident-to-services must be an integrated element of the physician’s services, the foundation for effective incident-to-billing. The physician must first provide health care services to the patient treated by the NPP “incident-to” the physician’s services. This criterion does not imply that a physician must have provided a service for each patient visit. Rather, a continuous course of therapy began by a physician and seen by the physician at the first appointment will qualify under the incident-to-billing requirements.

When treating patients for recurring, connected visits that also include new core complaints, physicians and physician group practices frequently ignore this. The Medicare and Medicaid programs focus on this issue when auditing and analyzing claims. As a result, physicians and their group practices should adopt policies and procedures to ensure that incident-to-services are only billed for core issues and complaints for which one of their physicians has seen a patient before an NPP delivers services.

  • Direct Supervision

The requirement for direct physician supervision of an NPP performing incident-to-services is one of the most misunderstood components of the incident-to-billing guidelines. Many state regulations allow advanced registered nurse practitioners (ARNPs) and physician assistants (PAs) to provide health care services to patients without a physician’s presence or direct supervision. Many of these state laws allow for “general” physician supervision.

However, incidental services must be provided under the direct supervision of a physician under the regulations of both Medicare and many states’ Medicaid programs. Direct supervision requires a physician to be immediately available to provide help and direction when an NPP performs services that the physician intends to bill as incident-to. The physician, while not required to be in the same room as the NPP, must be in the same office suite. By far, the incident-to-billing requirement is misunderstood and ignored by physicians and their group practices. Unfortunately, they frequently mix the direct supervision requirements for incident-to billing with the supervision requirements imposed by state law.

  • State Licensing Requirement

Another common misconception that physicians have when Billing Medicare’s incident-to-services is that an NPP might be licensed in another state and still give services to patients in the state where the physician’s practice is listed. However, incident-to-billing requirements for both the Medicare and Medicaid programs demand that the NPP be licensed or authorized to practice in the respective state before a physician can bill their services incidentally.

Failure to confirm that an NPP is appropriately licensed or certified to operate in the relevant state will result in an incorrect and perhaps false claim for incident-to-services. Furthermore, permitting an NPP to perform services when the NPP is not licensed or authorized to operate in the appropriate state might lead to claims from the Department of Health that a physician is aiding and abetting the unlicensed practice of medicine or nursing. Before allowing their NPPs to provide services to their patients and charge those services incidentally, physicians and their group practices must ensure that their NPPs are licensed or certified to practice in the applicable state.

Are you Getting 100% Reimbursement?

Undoubtedly, physicians can benefit from incident-to-billing to increase revenue in their practice by billing the nurse visit under the physician’s supervision. But how can you know if you’re following incident-to-billing guidelines?  Furthermore, keeping up with changes in claim procedures, guidelines, and billing technologies can be difficult for healthcare practice, especially for larger hospitals with trained billing staff.

That’s where the 24/7 Medical Billing Services team comes in, with decades of proven knowledge in medical billing service and revenue management. Contact us today to learn more about how we can help you collect money and serve patients better.

See also: Everything You Want To Know About “Incident To Billing”


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