Medicare Guidelines: Billing Services Incident-to


In order to bill incident-to for Medicare, that non-physician practitioner has to be eligible to be a Medicare provider in their own right. They have to be eligible to have their NPI and be a Medicare provider. And what this means specifically for nurse practitioners is that they must be masters degreed. Read this expert medical billing and coding training article that specially focuses on the incident-to services.

This changed few years ago and nurse practitioners had an opportunity to grandfather in even if they didn’t have a masters degree. But now, there is no opportunity for that. If a nurse practitioner does not have a master’s degree then she is not all ready Medicare eligible provider, she cannot get a provider number without obtaining that master's degree and she cannot bill incident-to either. She’s got to be eligible to bill Medicare under her own for her service to be billed as incident-to.

Incident-to services are billed under the physician’s number. So, on the claim form it looks just like the physician did it. There's no way on the current claim forms to identify that the service was actually done by a nurse practitioner or physician's assistant. These are paid at 100% of the physician fee schedule because of course it looks like the physician did it. And they're allowed to do anything within the supervising physician’s scope of practice. And that’s going to be pretty clear and pretty evident in those cases.

Incident-to Rules

It's incident-to a physician’s professional service. It's in the physician’s office. It's under the physician’s direct supervision and it's furnished by an individual who’s an employee of that physician. They're either an employee of the physician or they're an employee of the same entity that employs the physician. Now, this can be a W-2 employee. It can be a 1099 employee. That’s not the key, just that they're under the control and they represent an expense to that physician or to the same legal entity.

Incident-to the physician’s professional service

It's an integral, although incidental part of the physician’s professional service and here’s the kicker. That professional, that nurse practitioner, that PA is following a plan of care established by the physician. This is the hardest thing to nail down but it's critical. So, when we’re auditing a non-physician practitioner visit, we don't just look at the visit we’re auditing today, we have to look back in the chart and find a documented plan of care that that non-physician practitioner is following as per the healthcare guidelines.

The physician also – and has to perform the initial service and be involved in subsequent services of a frequency which reflects active participation and management which means it's got to be clear that that physician didn’t just completely turn that patient over to that nurse practitioner or PA, but that he set up that plan of care and he sees that patient on a regular basis.

Check with your Medicare Carrier

Some carriers will require something more specific. Some carriers say that the physician has to see the patient on every third visit. Whatever it is, if we’re going to bill an incident-to, it's got to be clear that that physician is seeing that patient on a regular basis.

So, if you are for example, an outside auditor or an auditor that is not physically located where the charts are or physically located where the medical records are, they can't just copy that one office’s and then sent it to you. If this was billed incident-to, you have to have access to the entire record as per Medicare guidelines. You have to go back in that record, find the visit where the plan of care was set up and see what that plan of care is so that we can make sure today’s visit really is following that plan of care. And then you have to be able to look back and see how often that physician saw that patient.

It also has to be furnished in the physician’s office or clinic. And you have to meet all of the requirements you have to meet for an office in other circumstances. You have to be paying the rent, has a pending utility, that has to be fair market value rent. It has to be the physician’s office. So, no new patients, no new problems in the physician’s office.

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